Hmong txiv neeb shamanism

1. Introduction

Version followed: the Hmong txiv neeb (shaman) tradition as Hmong community members and Hmong-led and hospital programmes in California's Central Valley describe it, chiefly the shaman programme at Mercy Medical Center, Merced (Dignity Health), with ethnography as attributed context. The psychotherapist's own work follows the DSM-5-TR Cultural Formulation Interview (CFI) and its supplementary modules.

What it is. The txiv neeb is a Hmong spiritual healer. Sources describe Hmong health in terms of the soul: many Hmong hold that most illness follows the soul separating from the body, for example after an accident, a traumatic event or theft by an angry spirit, and that the shaman communicates with the spirit world to retrieve it [source: CHCF 2020]. A University of Wisconsin clinical handout describes soul loss (poob plig) after sudden fright, excessive fear or grief, or capture by an evil spirit (dab), and spirits as ancestral, nature, domestic or evil [source: UW Aware Medicine]. The Religions in Minnesota glossary defines ua neeb as a ritual only a shaman can perform, which involves going into the spirit world, and hu plig as soul-calling [source: Carleton Religions in Minnesota]. These are the tradition's own explanations, reported here as Hmong sources and their scholars hold them.

Who holds authority. Sources describe a person being called to become a shaman through signs from the spirit world, often beginning with an unusual illness, and taught by a master shaman [source: CHCF 2020; UW Aware Medicine]. One handout states a shaman must first show they can heal their own family, that shamans may be men or women of any age, and that they usually take gifts rather than fees [source: UW Aware Medicine]. Major health decisions are often made with the family and the clan leader; there are 18 clans [source: UW Aware Medicine]. A Merced cultural specialist calls the shamans "the gatekeepers" [source: CHCF 2020]. A psychotherapist does not practise, simulate or direct any part of txiv neeb healing.

How change happens (in the tradition, and in the therapist's work). Ethnographic work with Fresno shamans identified detailed explanation of the illness, culturally meaningful symbols and community involvement, including communal rites that reintegrate the patient, as key healing elements [source: Ensign 1994, record]; a study of 924 shaman contact forms found shamans treated physical, emotional and psychological complaints, often attributed to soul loss or harmful spirits, and that rituals reinforce connections to family, culture and community [source: Helsel, Mochel & Bauer 2004, record]. The therapist's change model is different and parallel: understanding the client's and family's explanatory model, offering psychological care that fits it, and coordinating with the healer the family chooses, so that neither form of care undermines the other [synthesis].

Context. Many Hmong people in the US came as refugees from Laos after 1975, with large communities in California, Minnesota and Wisconsin [source: UW Aware Medicine]. Anne Fadiman's 1997 book on a Hmong child with epilepsy and her doctors is widely used as an account of cultural barriers in care [source: CHCF 2020; Wellcome Collection record]; it is an outsider's account and should be read as such [synthesis].

2. Framework

This is a healing tradition, not a psychotherapy. There are no therapist phases in the tradition itself. The framework below is for the psychotherapist's own culturally responsive work alongside it. Session counts are not set by any source and are [synthesis].

Phase 1: Engagement and set-up (session 1, sometimes before it).

Goals: arrange a trained professional interpreter (White Hmong or Mong Leng/Green Mong as needed) [source: UW Aware Medicine]; learn who the client wants involved (spouse, parents, head of household, clan leader); explain confidentiality and its limits; screen for risk and urgent medical need [synthesis].
Move on when: language access is in place, the client has said who may be involved, and no emergency needs handling first [synthesis].

Phase 2: Cultural assessment (sessions 1 to 3).

Goals: core CFI (16 questions, four domains) [source: APA CFI]; selected supplementary modules (Explanatory Model; Spirituality, Religion, and Moral Traditions; Immigrants and Refugees; Coping and Help-Seeking; Cultural Identity; Older Adults or School-Age Children and Adolescents as relevant) [source: APA Supplementary Modules]; Informant Version with a family member if the client agrees [source: APA Informant Version]; Kleinman's explanatory-model questions [source: Tanenbaum handout]; ask whether a txiv neeb or other healer has been consulted and what was said.
Move on when: the client's name for the problem, its cause, the help already sought (including any ceremony) and what the client hopes from therapy are known, and normative experience has been separated from possible disorder as far as possible [synthesis].

Phase 3: Cultural formulation and a shared plan (sessions 2 to 4).

Goals: write a formulation that holds both the client's explanatory model and the clinical picture; agree goals in the client's terms; agree whether, how and with whose consent to coordinate with a shaman, clan leader or hospital programme [synthesis].
Move on when: the client (and family where appropriate) agrees with the plan in more than a polite "okay"; one handout warns that a pressured "okay" can mean no [source: UW Aware Medicine].

Phase 4: Parallel treatment and coordination (most of the work; often 8 to 20 sessions for common presentations) [synthesis].

Goals: deliver the agreed psychological treatment; respect ceremonies the family arranges; coordinate with the healer if the client consents; integrate the meaning of ceremonies; review risk and medical needs regularly.
Move between phases backwards when: new symptoms, a crisis, a change in the family's view, or a shaman's or clan leader's advice changes the picture; return to Phase 2 and repeat the relevant module, which APA says may be used repeatedly during treatment [source: APA Supplementary Modules].

Phase 5: Review and ending.

Goals: review outcomes in the client's own terms and the clinical measures used; plan who the client will turn to (family, shaman, doctor, therapist) if difficulties return [synthesis].

3. Guiding principles

The tradition belongs to the community. Healing, ceremony and spirit work are for the txiv neeb the family chooses; the therapist never performs, imitates or advises on how they are done [synthesis].
Ask before assuming. The UW handout states that its own points are generalisations and the best approach is to ask the patient and family [source: UW Aware Medicine]. Practical meaning: every cultural statement in this guide is a question to put, not a fact about this client.
Attribute, do not adjudicate. Soul loss, spirits and the shaman's journey are described as the client holds them, neither confirmed nor dismissed [synthesis]. Practical meaning: say "in your understanding" or "as your family sees it", not "really" or "just".
The CFI supports, it does not diagnose. APA states the CFI is not meant to be the only basis for a diagnosis [source: APA CFI]. Practical meaning: use it to understand, then apply diagnostic criteria with care.
Normative experience is not illness. DSM and ICD-11 exclude trance or possession states that are part of broadly accepted cultural or religious practice [source: PMC9199574; findacode ICD-11 6B62]. Practical meaning: a shaman's trance, or a calling the community recognises, is not a symptom by itself.
Do not miss illness either. Distress, psychosis, depression, epilepsy or medical disease can coexist with a spiritual explanation [synthesis]. Practical meaning: assess fully even when the family's account is spiritual.
Family and clan are part of decisions, with the client's consent. Sources state the clan leader is expected to make major health decisions [source: UW Aware Medicine]. Practical meaning: ask the client whom to involve; never bypass a competent adult client.
Language access is clinical care. Use trained interpreters, not children or untrained relatives [source: UW Aware Medicine; synthesis on children].
Collaboration only with consent, and with community-recognised healers. The Merced programme lets any patient request shaman services [source: CHCF 2020]. Practical meaning: the client decides; the therapist does not recruit or recommend a particular shaman [synthesis].
Both-and, not either-or. Merced shamans are increasingly trained to refer patients to doctors, and one shaman reports telling patients to see the doctor first [source: The World 2013]. Practical meaning: present therapy as one form of help alongside, not instead of, the family's healer.
Respect the history. Many Hmong families carry war, displacement and early bad experiences with US health care; a Merced director said early mistakes were something staff "were not very proud of" [source: The World 2013]. Practical meaning: expect mistrust and earn trust.
Indirect disagreement. Dissatisfied patients may not criticise care and may quietly leave [source: UW Aware Medicine]. Practical meaning: check satisfaction often and in several ways.
Safety first, without misreading tradition. Coining, cupping and spooning should not be mistaken for abuse [source: UW Aware Medicine]; genuine harm and delay of urgent medical care are still safeguarding matters [synthesis].
Medicines and herbs go to the prescriber. The therapist never advises starting, stopping or changing a medicine or herbal remedy [synthesis].

4. Intervention inventory

All interventions below are the psychotherapist's own work. None of them is txiv neeb healing, and none involves taking part in, describing or directing a ceremony. Example language is illustrative and should be delivered through a trained interpreter where needed [synthesis unless tagged].

4.1 Cultural humility and self-examination

Purpose: notice the therapist's own assumptions about spirits, shamans, refugees and "compliance" before they shape assessment. Use before first contact and whenever the therapist feels impatience, curiosity that turns to fascination, or an urge to correct the family [synthesis].
Steps: (1) Before the first session, write down what you already believe about Hmong people and shamanism, and where those beliefs came from (news, Fadiman's book, training). (2) Mark which are generalisations; the UW handout itself warns its points may not apply to every clan or individual [source: UW Aware Medicine]. (3) Read Fadiman's account as an outsider's narrative of a single family, not a manual [synthesis]. (4) After sessions, note any moment you wanted to explain away or endorse a spiritual account, and bring it to supervision.
Example language (illustrative, to self or in supervision): "Am I hearing this family's view, or the book I read about another family?"
Watch for: exoticising (treating the client as a cultural specimen), and its opposite, ignoring culture altogether. Working: questions become more specific to this client and fewer assumptions appear in notes.

4.2 Working with trained interpreters and cultural brokers

Purpose: accurate understanding across White Hmong, Mong Leng and English; bridging concepts as well as words [source: UW Aware Medicine]. Use whenever the client or any family decision-maker is not fully fluent in the therapy language.
Steps: (1) Book a trained professional interpreter; avoid children and untrained relatives [source: UW Aware Medicine; synthesis on children]. (2) Pre-brief: purpose of the session, confidentiality, that you want terms such as poob plig or tu siab kept in Hmong and explained rather than translated into psychiatric labels. (3) Ask the client whether they are comfortable with this interpreter, given clan ties and small communities [synthesis]. (4) Speak in short units; look at the client. (5) Debrief: ask the interpreter about anything that was hard to render. (6) Where a cultural broker is available, use them to explain both sides' frames; at Merced an interpreter and cultural broker explains equipment by comparing how the doctor sees illness with how the shaman can "see spirits" [source: The World 2013].
Example language (illustrative): "Please keep the Hmong word if there is no English one, and tell me what it means to you."
Watch for: interpreter answering for the client, softening distress or risk, or the client holding back because the interpreter is known to the family. Working: the client corrects or expands what is said.

4.3 Engaging the family and clan, with the client's consent

Purpose: honour family and clan roles in health decisions [source: UW Aware Medicine] while protecting the client's own choices and confidentiality. Use at intake and before any major decision (hospital admission, medication referral, coordination with a shaman).
Steps: (1) Ask the client privately who usually takes part in health decisions (head of household, parents, spouse, clan leader). (2) Ask what the client wants shared, with whom, and what must stay private. (3) Record consent for each person and each type of information. (4) Offer a family meeting; for children, sources suggest directing communication to the father [source: UW Aware Medicine], while also hearing the child and the mother [synthesis]. (5) For a competent adult, the final decision remains the client's in law [synthesis]. (6) The UW handout advises not giving grave news directly to the patient before speaking with family or clan leaders [source: UW Aware Medicine]; in therapy, ask the client in advance how they would want serious news handled [synthesis].
Example language (illustrative): "In your family, who usually helps decide about health? Would you like them here, and what should stay between us?"
Watch for: family members speaking for an adult client, especially around gender, marriage or intergenerational conflict; the client saying "okay" under pressure, which may mean no [source: UW Aware Medicine]. Working: the client speaks freely both with and without family present.

4.4 The core DSM-5-TR Cultural Formulation Interview

Purpose: clarify the problem from the perspective of the person and their social network: its meaning, sources of help and expectations of services [source: APA CFI]. Use at the first assessment with every Hmong client, and again when care stalls.
Steps (structure per APA, in your own words; the form may be reproduced by clinicians for use with their patients) [source: APA CFI]: (1) Cultural definition of the problem: how the client names and describes it, and what troubles them most. (2) Cultural perceptions of cause, context and support: what caused it, what family and community say, stressors and supports, and how identity (Hmong, refugee, clan, generation, religion including Christian or traditional) bears on it. (3) Self-coping and past help seeking: what the client has done, including any txiv neeb consultation, herbal or other healers, doctors, church; and what got in the way. (4) Current help seeking: what the client wants now, and what might hinder trust in this clinician, such as language or perceived racism. (5) Use the core form's pointers to open the relevant supplementary module. Field-trial timings of about 15 to 20 minutes are [uncertain].
Example language (illustrative): "People explain problems like this in different ways. How would you describe what is happening, in your own words?" / "Have you or your family asked anyone else for help, such as a shaman, a pastor or a doctor?"
Watch for: answers framed politely to please the clinician; reluctance to name a shaman consultation for fear of judgement. Working: the client offers their own terms and discloses traditional help seeking.

4.5 CFI Informant Version

Purpose: hear a family member's or friend's understanding (17 questions; the first covers the informant's relationship to the patient) [source: APA Informant Version]. Use when family shape decisions, with children, older adults, or when the client cannot give a full account.
Steps: (1) Get the client's consent. (2) Meet the informant separately or jointly as agreed. (3) Cover the same four domains as the core CFI. (4) Note where family and client views differ (for example, a spiritual cause for the family, a stress cause for a younger client) without ranking them [synthesis].
Example language (illustrative): "As her father, what do you think has caused this, and what do you think would help?"
Watch for: the informant's view replacing the client's. Working: the formulation shows both views and where they agree.

4.6 Supplementary modules most relevant to Hmong clients

Purpose: in-depth assessment of specific areas; APA says modules can be add-ons or standalone, used at first evaluation, later, or repeatedly [source: APA Supplementary Modules]. Select by need.
Steps: (1) Explanatory Model: the client's understanding of cause, course and treatment. (2) Spirituality, Religion, and Moral Traditions: traditional practice, Christian conversion, mixed households, and the role of ancestors and spirits as the client holds them. (3) Immigrants and Refugees: migration history, losses, camps, resettlement and acculturation. (4) Coping and Help-Seeking: including txiv neeb, herbalists and church. (5) Cultural Identity: Hmong identity, clan, generation, language. (6) Older Adults or School-Age Children and Adolescents as relevant; Caregivers for the person caring for the patient [source: APA Supplementary Modules for module names; content choices synthesis].
Example language (illustrative): "Some families follow the old Hmong ways, some are Christian, some mix both. What is it like in your home?"
Watch for: religious difference inside the family (for example, traditional parents and Christian adult children) as a source of conflict over whether to call a shaman [synthesis]. Working: the client can describe spiritual life without defensiveness.

4.7 Kleinman's explanatory-model questions

Purpose: elicit the client's model of the illness (Kleinman, Eisenberg and Good, 1978) [source: Dinos et al. 2017 via Cambridge; Tanenbaum handout]. Use alongside or instead of the CFI Explanatory Model module, and whenever treatment goals clash.
Steps (paraphrased eight questions) [source: Tanenbaum handout]: ask (1) what the client calls the problem; (2) what caused it; (3) why it started when it did; (4) what it does inside them and how it works; (5) how severe it is and whether it will be short or long; (6) what treatment they think they should receive; (7) the main problems it has caused; (8) what they fear most about it. Then summarise the model back and check it.
Example language (illustrative): "What do you fear most about this?" / "If your soul has been frightened away, as your mother thinks, what would need to happen for you to feel whole again?"
Watch for: the therapist translating the model into a diagnosis too quickly. Working: the client agrees with the summary and adds to it.

4.8 Asking about txiv neeb consultation without judgement

Purpose: learn what spiritual help has been sought, what the shaman advised, and whether ceremonies are planned, so care can be timed and coordinated. Use at intake and when the client mentions spirits, soul loss or family pressure.
Steps: (1) Normalise: many families use both doctors and shamans; small surveys in a UW handout put regular shaman use at about 75% [source: UW Aware Medicine]. (2) Ask what was done in general terms only (who, when, what the shaman said the problem was, what the family expects) and never ask for ceremony details, chants or objects [synthesis]. (3) Ask how the client felt about it and whether it helped. (4) Ask whether a ceremony is planned and whether it affects appointments. (5) Record it as part of help seeking, not as a risk factor.
Example language (illustrative): "Many Hmong families see a txiv neeb as well as a doctor. Has your family done that? What did the shaman say was happening?"
Watch for: the client minimising or hiding traditional care; a client who feels pressured into, or excluded from, a ceremony. Working: open disclosure and willingness to plan around ceremonies.

4.9 Hmong idioms of distress and DSM-5-TR cultural concepts of distress

Purpose: hear distress in the client's own terms. DSM-5-TR treats cultural concepts as idioms, explanations or perceived causes, and syndromes [source: APA Section III]. The DSM-5-TR glossary list does not include a Hmong-specific concept [source: UNMC slides]. Use when the client names a Hmong idiom.
Steps: (1) Note the term and its everyday meaning to the client. Examples from sources: poob plig, soul loss after fright, grief, fear or spirit capture [source: UW Aware Medicine]; tu siab, translated literally as "broken liver", a term for sadness that is shaped by ideas about social relationships, morality and cosmology [source: Postert et al. 2012, record]. Fresno reporting describes spirit-leaving-the-body imbalance after trauma that a Western clinician might call depression [source: California Health Report 2012]. (2) Ask whether this is an explanation (a cause), an idiom (a way to say "I suffer"), or a named condition for the client. (3) Use the term in your own language with the client. (4) Assess separately for depression, anxiety, PTSD and other conditions. (5) Note in the formulation how the idiom relates to diagnosis, not as an equivalent [synthesis]. Other Hmong terms often discussed (such as nyuaj siab, and the term for the condition in Fadiman's book) were not confirmed in the sources used here [uncertain: not verified].
Example language (illustrative): "When you say tu siab, what is it like for you? Is it the same as feeling sad, or different?"
Watch for: using a Hmong term as if it were a diagnosis, or assuming every client uses it. Working: the client uses the term and the clinical language side by side.

4.10 Distinguishing culturally normative experience from disorder

Purpose: avoid both pathologising Hmong spiritual experience and missing illness. Use when a client reports spirit encounters, soul loss, a calling to become a shaman, or trance-like states.
Steps: (1) Remember the rules: DSM-5 dissociative trance does not apply when the trance is "a normal part of a broadly accepted collective cultural or religious practice" [source: PMC9199574]; DSM-5 DID criterion D excludes disturbance that is a normal part of accepted cultural or religious practice [source: PMC9199574] (DSM-5-TR keeps this in substance [source: https://umsystem.pressbooks.pub/aswbprep/?p=1299]; that the exact wording is the same is [uncertain]); ICD-11 6B62 trance disorder and 6B63 possession trance disorder require states that are involuntary and unwanted and not part of accepted practice, with distress or impairment [source: findacode ICD-11 6B62; PMC9199574]. (2) A shaman's trance during ua neeb is part of accepted practice and is not a symptom [synthesis from the above]. (3) A calling to become a shaman is often reported to begin with an unusual illness [source: UW Aware Medicine; CHCF 2020]; if a client describes this, ask how the family and a recognised shaman understand it, and assess separately for medical and psychiatric conditions [synthesis]. (4) Ask whether the experience is shared and recognised by family and community, whether it is wanted, whether it fits the expected form, and whether it impairs functioning. (5) Screen for psychosis, mood disorder, PTSD, substance use and neurological causes (seizures, sleep disorders) with the GP or psychiatrist [synthesis]. (6) Consult a cultural broker or, with consent, a family member or recognised community figure about whether the experience fits norms [synthesis]. (7) Document both the cultural meaning and the clinical findings.
Example language (illustrative): "In your family's understanding, is this the kind of thing that happens when someone is called by the spirits? What do others who know about these things say?" / "Alongside that, I want to check your sleep, mood and health, so nothing is missed."
Watch for: experiences that are unwanted, frightening, not recognised by the family or shaman, or accompanied by disorganisation, command content, suicidality or self-neglect; these need psychiatric assessment whatever their meaning. Working: a formulation that the client and family accept and that does not delay needed care.

4.11 Collaboration and referral with a txiv neeb chosen by the client

Purpose: support parallel care when the client wishes. Sources report Hmong patients often seeing a shaman before a doctor [source: The World 2013] and shamans referring to doctors [source: CHCF 2020; The World 2013]. Use when the client or family asks for a shaman, or when ceremonies affect treatment.
Steps: (1) Let the client lead: the family chooses and contacts the shaman, usually through family or clan networks; the therapist does not choose, recommend or arrange a specific shaman [synthesis]. (2) Get written consent for any contact, specifying what may be shared. (3) If contact is wanted, offer a brief, respectful conversation (with an interpreter) about the client's wellbeing, timing of ceremonies and appointments, and shared warning signs that should prompt medical or crisis contact [synthesis]. (4) Never ask the shaman to explain or perform ritual content. (5) Agree how each will respond if the client gets worse. (6) Record the arrangement.
Example language (illustrative, to client): "If it would help, I am happy to work alongside the shaman your family trusts. You decide whether we speak and what I can share." (to shaman, via interpreter) "I respect your work for the family. I would like us both to know when the client needs a doctor urgently."
Watch for: pressure on the client from either side; confidentiality leaks in small communities; a plan that delays urgent medical care. Working: the client experiences the two forms of help as aligned.

4.12 Working within hospital and community programmes (Merced model)

Purpose: use established institutional pathways where they exist. At Mercy Medical Center, Merced, a 40-hour certification orients shamans to Western medicine (germ theory, vaccines, prescription drugs), graduates receive a certificate and a Dignity Health badge, more than 150 shamans have been trained, any patient may request shaman services, and shamans may perform nine hospital-approved ceremonies in the patient's room [source: CHCF 2020]. A 2009 newspaper report named soul calling among the approved ceremonies and soft-voiced chanting [source: Pluralism Project summary of NYT 2009]. The programme, called Partners in Healing, was described in 2013 as in its twelfth year [source: The World 2013]. The year the hospital adopted it as formal policy (often given as 2008) is [uncertain: not verified]. Fresno County's 2012 MHSA-funded wellness centre plan included cross-training shamans and staff, with no ceremonies held on site [source: California Health Report 2012]. Use for inpatient clients or when liaising with a hospital.
Steps: (1) Find out whether the hospital or service has a shaman, chaplaincy or mission integration policy. (2) Route the family's request through that office rather than arranging anything yourself. (3) Explain to ward staff, with consent, what the request means to the client. (4) Where no policy exists, advocate for the family's request to be heard by the service's chaplaincy, cultural or patient-experience lead [synthesis]. (5) Do not promise anything the service has not approved.
Example language (illustrative): "This hospital has a way for families to request a shaman visit. I can put you in touch with the office that handles it."
Watch for: staff removing protective strings or refusing requests without explanation; sources report earlier clashes over string-tying, especially around the neck [source: CHCF 2020]. Working: the family feels its request was respected and safety concerns were explained.

4.13 Bridging explanations of treatment

Purpose: explain therapy, assessments, medication referrals or procedures in terms that fit the family's frame, as the Merced cultural broker does with equipment [source: The World 2013]. Use when introducing therapy, psychiatric referral, admission or tests.
Steps: (1) Ask what the client already understands. (2) Explain the purpose and what will happen, concretely; the UW handout recommends visual and hands-on teaching and quantifying things such as blood taken [source: UW Aware Medicine]. (3) Link therapy to goals the client named (sleep, family harmony, strength to work) [synthesis]. (4) Address beliefs that may cause fear, such as surgery being thought to open the body to evil spirits [source: UW Aware Medicine], by passing the question to the medical team. (5) Check understanding by asking the client to explain it back.
Example language (illustrative): "The shaman looks after the soul. In therapy we work on worry, sleep and what happened to you, so your mind can rest. Both can go on together."
Watch for: the explanation implying the shaman's work is unnecessary. Working: the client can describe why each form of care is happening.

4.14 Integrating ceremony and healing experiences into therapy

Purpose: help the client make use of what a ceremony meant for them (relief, reconnection with family, renewed obligations, or disappointment). Ethnography links Hmong healing to explanation, symbols and community reintegration [source: Ensign 1994, record; Helsel et al. 2004, record]. Use after a ceremony or a significant consultation.
Steps: (1) Ask how the client feels since, without asking what was done. (2) Explore what changed in relationships, sleep, mood and worry. (3) Link any relief or support to therapy goals. (4) If the ceremony did not help, explore the meaning (fear that something is seriously wrong, guilt, family tension) and reassess risk and medical need [synthesis]. (5) Respect any obligations the client now holds.
Example language (illustrative): "How have you been since the ceremony? What feels different with your family?"
Watch for: hopelessness after an unsuccessful ceremony; the UW handout reports a shaman saying that failure to improve with medicine suggests a soul problem [source: UW Aware Medicine], and the reverse may be felt too [synthesis]. Working: the client can talk about both forms of help openly.

4.15 War, displacement and intergenerational context

Purpose: place distress in its history: service with the CIA in Laos, large losses, flight to Thailand, resettlement from the 1980s and a later group since 2004 [source: UW Aware Medicine]. Use with refugees and their children.
Steps: (1) Use the Immigrants and Refugees module [source: APA Supplementary Modules]. (2) Take a gentle trauma history, paced by the client. (3) Assess PTSD, depression and grief with validated measures where available in Hmong, noting translation limits [synthesis]. (4) Explore intergenerational gaps in language, religion and expectations. (5) Offer evidence-based trauma treatment adapted with the client, alongside any spiritual care they choose [synthesis].
Example language (illustrative): "Many Hmong families went through war and long journeys. You don't need to tell me everything. What would help me understand?"
Watch for: overwhelm or dissociation during history taking; somatic complaints as the main expression of distress. Working: the client links past events and present symptoms at their own pace.

4.16 Stigma-sensitive framing of mental health

Purpose: reduce shame. Fresno reporting notes that stoic immigrants may see mental health problems as weakness [source: California Health Report 2012]. Use at referral and engagement.
Steps: (1) Use the client's words for the problem, not psychiatric labels, until they invite them. (2) Frame therapy around strength, sleep, family harmony and coping. (3) Keep confidentiality visible, especially regarding the community [synthesis].
Example language (illustrative): "Strong people carry heavy things. This is a place to put some of it down."
Watch for: missed appointments as silent disagreement [source: UW Aware Medicine, on indirect dissatisfaction]. Working: steady attendance and the client raising new topics.

4.17 Safeguarding and urgent medical need

Purpose: protect clients without misreading tradition. Use whenever there is risk to life, a child, or a delay of urgent medical care.
Steps: (1) Know that coining, cupping and spooning marks are not by themselves abuse [source: UW Aware Medicine]. (2) Assess actual harm in the usual way; apply local child and adult safeguarding procedures to genuine injury, neglect or coercion whatever the stated reason [synthesis]. (3) Where a family prefers to wait for a ceremony before urgent medical care, explain the medical risk clearly, involve the client's doctor, and support both proceeding together; the Merced shaman who advises seeing the doctor first is a useful model [source: The World 2013]. (4) Conduct standard suicide risk assessment and safety planning, including lethal-means counselling about storage and removal [synthesis]. (5) Document cultural context and the safeguarding reasoning.
Example language (illustrative): "I respect that your family wants a ceremony. The doctors also need to see her today, because this could be dangerous. Can both happen?"
Watch for: epilepsy, diabetes or other conditions where delay is harmful (Hmong has no word for diabetes; one rendering is "sweet blood") [source: CHCF 2020]. Working: urgent care happens and the family still feels respected.

4.18 Medicines, herbs and other remedies: routing to the prescriber

Purpose: keep the client safe when herbal or other traditional remedies are in use [source: UW Aware Medicine mentions herbs]. Use whenever the client mentions remedies alongside prescribed medication.
Steps: (1) Ask, without judgement, what remedies the client uses. (2) Do not advise on starting, stopping, combining or preparing any remedy or medicine. (3) With consent, tell the prescriber or GP so interactions can be checked [synthesis].
Example language (illustrative): "Your doctor should know about everything you take, including Hmong medicines. Shall I let them know, or would you like to tell them?"
Watch for: stopping prescribed medication because a ceremony or remedy is felt to have worked. Working: the prescriber is informed and the client stays engaged.

5. Handling problems

Sources on Hmong shamanism give little direct guidance for psychotherapy problems; most responses below are [synthesis], built on the principles and sources above.

Polite agreement, then non-attendance. A pressured "okay" can mean no, and dissatisfied patients may leave quietly [source: UW Aware Medicine]. Response: ask open questions about doubts, offer choices rather than yes/no questions, check by phone through the interpreter after missed sessions, and invite the family member who influences decisions [synthesis].
The family wants the shaman and not therapy. Response: do not compete. Ask what the family hopes the shaman will change, offer therapy as help for sleep, worry or stress alongside it, and keep the door open; schedule around ceremonies [synthesis].
The client wants therapy, the family wants only ceremony (or the reverse). Response: meet the client alone, clarify what the client wants, and help them find words for the family; with consent hold a family meeting; respect the client's legal autonomy as an adult [synthesis].
Religious split in the family (traditional practice versus Christian conversion). Response: use the Spirituality, Religion, and Moral Traditions module [source: APA Supplementary Modules]; do not take sides; explore how decisions about calling a shaman are made [synthesis].
The ceremony "did not work" and the client is frightened. Response: reassess risk, mood and medical status, explore meaning, liaise with the doctor, and consider whether the family wishes to consult the shaman again; avoid implying the spiritual explanation was wrong [synthesis].
Unclear whether an experience is a calling, a spiritual event, or psychosis. Response: follow 4.10; consult a cultural broker and psychiatrist; keep the client safe while the picture clarifies; do not decide the spiritual question yourself [synthesis].
Overwhelm during trauma history. Response: slow down, use grounding, return to present-day goals, and resume history later at the client's pace [synthesis].
Rupture after a clinician dismissed the spiritual explanation (in your service or elsewhere). Response: name it, apologise for any part your service played, ask what the client needs to feel respected, and restate that their view is welcome [synthesis]. A Merced director's acknowledgement that early mistakes were something staff were not proud of shows institutions owning this history [source: The World 2013].
Interpreter problems (known to the family, gender mismatch, softening content). Response: offer a different interpreter or telephone interpreting from outside the area; brief the interpreter on verbatim rendering of distress and risk [synthesis].
Gender and touch. Sources advise appropriate distance between men and women and note handshakes are not traditional [source: UW Aware Medicine]. Response: let the client lead on greeting; no touch without explicit consent; never sexual touch [synthesis].
Hospital staff resisting a ceremony request or removing strings. Response: route the request to the hospital's policy office; explain the meaning to staff with consent; where no policy exists, point to the Merced programme as a working model [source: CHCF 2020; synthesis].
Delay of urgent medical care. Response: as 4.17; involve the doctor at once; support parallel ceremony and treatment; follow safeguarding procedures where a child or dependent adult is at risk [synthesis].
Requests for the therapist to take part in or explain ceremonies. Response: decline warmly; the shaman and family hold that authority [source: CHCF 2020 on shamans as gatekeepers; synthesis].
Outsider accounts shaping expectations (for example, staff relying on Fadiman's book). Response: treat it as one family's story told by an outsider; ask this family directly [synthesis].
Evidence for formal collaboration models. Trials of collaborative care with traditional and faith healers exist in West Africa (for example a trial in Nigeria and Ghana reported in 2020), but their results are [uncertain: not verified] and none concerns Hmong shamans; Merced's programme is described in reporting and a 2004 contact-form study rather than in outcome trials [source: Helsel et al. 2004, record; CHCF 2020].

Sources

Hmong-specific sources:

Cultural assessment sources:

Books and papers cited:

Fadiman A. (1997; first paperback edition 1998). The spirit catches you and you fall down: a Hmong child, her American doctors, and the collision of two cultures. Farrar, Straus and Giroux.
Kleinman A, Eisenberg L, Good B (1978). Culture, illness, and care: clinical lessons from anthropologic and cross-cultural research. Annals of Internal Medicine 88:251-258 [page range uncertain].

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