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Vietnamese Amerasians and the former political prisoners of South Vietnam are living legacies of the Vietnam War. Now that many live in the United States, it is important for psychiatrists to have an understanding of their life experiences and be able to recognize psychiatric disorders that are common among them.
Vietnamese Amerasians and the former political prisoners of South Vietnam are living legacies of the Vietnam War. Now that many live in the United States, it is important for psychiatrists to have an understanding of their life experiences and be able to recognize psychiatric disorders that are common among them. Both groups present diagnostic and therapeutic challenges because of their extensive histories of trauma and cultural traditions that differ from mainstream patients. Their stories illustrate the multiple stressors that affect immigrant and refugee populations, such as adapting to unfamiliar cultural practices, learning new languages, finding ways to support themselves and their families, and crafting an identity that integrates who they were and who they have become. Finally, they demonstrate a resilience that allows them to overcome seemingly insurmountable obstacles and move on despite overwhelming experiences and losses.
Vietnamese Amerasians are the children of American men and Vietnamese women born during the years of major United States involvement in Vietnam-1962 to 1975. Unlike the French, who offered citizenship and the opportunity to live and be educated in France to their "Eurasian" offspring,1 the US government exhibited a highly ambivalent attitude toward its children in Vietnam, initially denying responsibility for them and then (beginning in 1979) processing their applications for immigration to the United States under the Orderly Departure Program (ODP).2
In 1987 Vietnamese Amerasians were given special priority status under the ODP with the Amerasian Homecoming Act (AHA).3 Between 1979 and 1999 a total of 89,467 Amerasians and their family members entered the United States under the terms of the ODP and AHA.4
Vietnamese Amerasians' status changed radically after the passage of the AHA. As if by an alchemist's hand, the "dust of life" were transformed into "golden passports" (a Vietnamese metaphor used to describe Amerasians), which allowed them and their close relatives to immigrate to the United States.3,5 Vietnamese persons claiming to be Amerasian or family members of Amerasians could immigrate to the United States with relative ease and safety. By 1993 immigration fraud had become so acute that it was difficult for legitimate Amerasians and their relatives to gain acceptance to the resettlement program, and the Amerasian Transit Center in Saigon, a collecting point for Amerasians and their families, closed.6,3 There are still an undetermined number of Amerasians in Vietnam, but their chances of ever reaching the United States are remote.
Adjusting to a new country
An early study of Vietnamese Amerasian children placed in the United States by the US Catholic Conference found serious adjustment problems, including running away, depression, and withdrawal-behaviors correlated with not living with their biological mothers and having had no formal education in Vietnam.7 This study also contradicted the perception that Amerasians were the products of brief liaisons, noting that their mothers had on average lived with their fathers for 2 years.
Subsequently, Nicassio and associates,8 using the Personality Inventory for Children, found higher levels of psychological distress in Amerasians than would typically be found in a nonclinical US sample. In addition, problems adjusting to American life were reported to Mutual Assistance Associations by 83% of Amerasians during their first 2 years in the United States, and after 4 years, 62% reported difficulties related to having an unstable home, being male, having a father from a minority group, and living outside the Southeast Asian community.9
Two later studies comparing the lives of Amerasians in the United States with those of Vietnamese immigrants found that despite early adversity and ongoing psychological distress, most Amerasians were able to adapt to life in the United States at levels comparable to those of other Vietnamese immigrants.3,10 Amerasians' higher levels of psychological distress were often related to their experiences of discrimination and poverty in Vietnam,6,11 paternal loss,12 maternal abandonment,13 identity issues related to mixed ethnicity,1,6,14 and a perceived lack of like-ethnic community support in the United States.10FORMER POLITICAL PRISONERS OF VIETNAM
Former US allies in the South Vietnamese government and military faced a different set of challenges. Those who were unable or unwilling to leave Vietnam at war's end were quickly rounded up and sent to reeducation camps, ostensibly to learn about the new government and its policies, but really to be isolated as potentially dangerous enemies and subjected to forced labor, brainwashing, and torture.2 Depending on the government's perception of their "crimes," prisoners remained in the camps from a few months to more than 20 years.
After being released, former prisoners had to adjust to life in a country that had been turned upside down. Once privileged, they were now outcasts and struggled to provide for themselves and their families. Many became sick under the camps' brutal conditions and had to depend on their families for support. Their wives often took on the head-of-household duties-traditionally not a woman's role in Vietnam-and this led to painful readjustments in marital and familial relationships. Eventually granted special refugee status by the United States, former political prisoners who had spent 3 or more years in reeducation camps were permitted to immigrate to the United States with their families.2
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.
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