April 15, 2008
Psychiatric Times.
No. 5
Vietnamese Amerasians and Former Political Prisoners
Robert McKelvey, MD
Dr McKelvey is professor of psychiatry and director in the division of child and adolescent Psychiatry, Oregon Health and Science University, in Portland. His interest in the Vietnamese people began with his study of the Vietnamese language at the Defense Language Institute and his subsequent service as a Civil Affairs officer in the United States Marine Corps during the Vietnam War. He reports no conflicts regarding the subject matter of this article.
Adjusting to a new country
Unlike Vietnamese Amerasians, former political prisoners of Vietnam have attracted far less attention from the American public. Only 3 quantitative studies were found that addressed their adjustment to life in the United States.
The first was a validation of the use of the Harvard Trauma Questionnaire to detect posttraumatic stress disorder (PTSD) and depression.15 This study was followed by another that examined the relationship between experiences of torture and PTSD and depression.16 Compared with Vietnamese persons who had not undergone torture, the former prisoners with more experiences of torture evidenced higher rates of PTSD and depression. A dose-effect relationship between torture and psychiatric symptoms was found, with the strongest relationship between torture and increased arousal. The third study examined predictor variables for psychological well-being. Those significantly related to well-being were psychological distress, social support, physical health, and age. The levels of psychological distress found in prisoners were at the clinical cutoff point of the instrument used, suggesting that there was a possible risk of mental health problems.17
In-depth interviews of former Vietnamese political prisoners revealed coping strategies that they had used to survive years of imprisonment in reeducation camps and adaptive characteristics that had helped them adjust to new lives in the United States.2
One trait associated with successful adaptation was the ability to develop or rediscover a cognitive approach that would help them to cope with the brutality and deadening routine of the camps. One man used techniques suggested by Dale Carnegie in How to Stop Worrying and Start Living, another developed a philosophy based on the writings of the French Stoics, and yet another invented a breathing and mind-cleansing technique based on yoga.
A second adaptive trait was to focus on the present, and what could be done in the future, rather than being seduced by memories of the past and all that was lost, which led only to anger and despair.
Finally, believing that you were supported by your family, and especially that your children understood, respected, and valued your suffering and did not see you as a failure because of all that you had lost seemed to fortify the former prisoners in their adaptation to life in and after the camps.
DIAGNOSTIC AND THERAPEUTIC ISSUES
While they seem to be members of American ethnic minorities, Amerasians are acculturated Vietnamese and must be treated within this context. They may struggle with issues surrounding abandonment, adoption, and biracialism.1 The occurrence of psychological disorders, especially depression and alcohol abuse, are higher in this group than in other like-aged Vietnamese refugees.2
In addition to their strong and proud Vietnamese identity, former political prisoners have much in common with other combat veterans and torture victims and are more likely than other Vietnamese refugees to have depression and PTSD.18 They also may be elderly and thus may have common psychiatric disorders associated with old age, such as anxiety, dementia, depression, schizophrenia, and substance abuse.19 Well-validated screening instruments, such as the Hop- kins Symptom Checklist-25 and the Harvard Trauma Questionnaire, are available in Vietnamese for use in this population.18
Within the Vietnamese cultural tradition, most mental health problems, such as anxiety and depression, are viewed as problems of life rather than illnesses requiring treatment. Severe psychotic illnesses, such as schizophrenia, on the other hand, are thought to have a supernatural origin and the Vietnamese will often first turn to those who deal with the supernatural (eg, shamans, astrologers, and fortune-tellers) for help.
Vietnamese persons will only present for psychiatric treatment when their behaviors have outstripped the family's capacity to manage them at home, including the use of physical restraint. As a result, their mental health problems are likely to be at an advanced stage when they do present to clinicians.20
Therapeutic strategies must be adapted to fit within the Vietnamese cultural context.21 Self-exploratory and revealing types of psychotherapy are likely to be less acceptable to these patients than supportive therapies that focus on solving practical problems with housing, medical care, and employment, along with therapies that use practical, concrete strategies, such as cognitive-behavioral therapy.22 Medications prescribed by a physician are usually welcome, but must be administered cautiously because of ethnic differences in pharmacodynamics, the concurrent use of eastern medicines, and issues with compliance, such as beliefs that western medications are "hot" and too strong for Vietnamese persons, leading to self-reductions in dosage to nontherapeutic levels.21,23
Despite the difficulties of engaging and treating these patients, caring for them is a very rewarding and interesting experience that opens windows of understanding into the long-term effects of war and the resiliency of the human spirit.
• Felsman JK, Johnson MC, Leong FT, Felsman IC. Vietnamese Amerasians: Practical Implications of Current Research. Washington, DC: Office of Refugee Resettlement; 1989.
• McKelvey RS, Webb JA. A comparative study of Amerasians, their non-Amerasian siblings, and unrelated like-aged Vietnamese immigrants. Am J Psychiatry. 1996;153:561-563.
References
1. Bemak F, Chung RCY. Vietnamese Amerasians: psychosocial adjustment and psychotherapy. J Multicult Couns Devel. 1997;25:79-88.
2. McKelvey RS. A Gift of Barbed Wire: America's Allies Abandoned in South Vietnam. Seattle: University of Washington Press; 2002.
3. United States General Accounting Office. Vietnamese Amerasian Resettlement: Education, Employment, and Outcomes in the United States. Washington, DC: United States General Accounting Office; 1994. GAO/ PEMD-94-15.
4. McKelvey RS. Vietnamese Amerasians. In: Ender MG, ed. Military Brats and Other Global Nomads: Growing Up in Organization Families. Westport, Conn: Praeger Publishers; 2002:53-65.
5. Moore J. Amerasians provide an exit. Far East Econ Rev. 1990;149:54.
6. McKelvey RS. The Dust of Life: America's Children Abandoned in Vietnam. Seattle: University of Washington Press; 1999.
7. United States Catholic Conference. In Our Fathers' Land: Vietnamese Amerasians in the United States. Washington, DC: United States Catholic Conference; 1985.
8. Nicassio PM, LaBarbera JD, Coburn P, Finley R. The psychosocial adjustment of the Amerasian refugees. Findings from the Personality Inventory for Children. J Nerv Ment Dis. 1986;174:541-544.
9. Felsman JK, Johnson MC, Leong FT, Felsman IC. Vietnamese Amerasians: Practical Implications of Current Research. Washington, DC: Office of Refugee Resettlement; 1989.
10. McKelvey RS, Webb JA. A comparative study of Vietnamese Amerasians, their non-Amerasian siblings, and unrelated like-aged Vietnamese immigrants. Am J Psychiatry. 1996;153:561-563.
11. Nguyen TST. Adjustment and Acculturation Problems of Vietnamese-Amerasians in Pittsburgh, Pennsylvania: A Post-resettlement Study [dissertation]. Pittsburgh: University of Pittsburgh; 1996.
12. Bemak F, Chung RCY. Vietnamese Amerasians: the relationship between biological father, psychological distress, and self-destructive behavior. J Community Psychol. 1999;27:443-456.
13. McKelvey RS, Webb JA. Long-term effects of maternal loss on Vietnamese Amerasians. J Am Acad Child Adolesc Psychiatry. 1993;32:1013-1018.
14. Anis J. Psychosocial adjustment of the Vietnamese-Amerasians [abstract]. In: Dissertation Abstracts International: Section B: The Sciences and Engineering. Vol 57. 1997:4777.
15. Smith Fawzi MC, Murphy E, Pham T, et al. The validity of screening for post-traumatic stress disorder and major depression among Vietnamese former political prisoners. Acta Psychiatr Scand. 1997;95:87-93.
16. Mollica RF, McInnes K, Pham T, et al. The dose-effect relationships between torture and psychiatric symptoms in Vietnamese ex-political detainees and a comparison group. J Nerv Ment Dis. 1998;186:543-553.
17. Nguyen WH. Psychological well-being of the former Vietnamese political prisoner in the United States [abstract]. In: Dissertation Abstracts International Section A: Humanities and Social Sciences. Vol 55. 1995:3314.
18. Mollica RF, Wyshak G, de Marneffe D, et al. Indochinese versions of the Hopkins Symptom Checklist-25: a screening instrument for the psychiatric care of refugees. Am J Psychiatry. 1987;144:497-500.
19. Bartels SJ, Dums AR, Oxman TE, et al. Evidence-based practices in geriatric mental health care. Psychiatr Serv. 2002;53:1419-1431.
20. Phan T. Investigating the use of services for Vietnamese with mental illness. J Community Health. 2000;25:411-425.
21. Kinzie JD, Leung P, Boehnlein JK, Fleck J. Antidepressant blood levels in Southeast Asians. Clinical and cultural implications. J Nerv Ment Dis. 1987;175:480-485.
22. Morris P, Silove D. Cultural influences in psychotherapy with refugee survivors of torture and trauma. Hosp Community Psychiatry. 1992;43:820-824.
23. Lin KM, Shen WW. Pharmacotherapy for southeast Asian psychiatric patients. J Nerv Ment Dis. 1991; 179:346-350.
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