Vietnamese Refugees' Levels of Distress, Social Support, and Acculturation: Implications for Mental Health Counseling.

This study examines psychosocial adjustment issues for two different groups of Vietnamese refugees and provides recommendations for mental health interventions. The findings show significant differences in levels of distress, social support and acculturation between the two groups and may be generalized to other refugee populations. The findings also suggest that mental health professionals need to be aware of intergroup and gender differences in refugee psychosocial adjustment and understand the importance of pre- and postmigration issues to be effective mental health counselors.

Since the fall of Saigon in 1975, a large number of Vietnamese refugees have entered the United States. The first wave of Vietnamese refugees arrived between 1975 and 1977 (Chung, Bemak, & Okazaki, 1997) and were generally well educated and proficient in English. Due to their contact and cooperation with Americans during the war, they were targets of the Vietcong resulting in the U.S. government airlifting and sealifting many of them out of Vietnam. In contrast, the second and subsequent wave of refugees arrived in the United States after 1978, during the postwar era, leaving Vietnam by sea on makeshift boats and rafts, so that they are often referred to as boat people. Many in this group suffered atrocities during their escape and were victims of torture, starvation, malnutrition, assault, rape, and/or robbery, with many children witnessing these atrocities (Chung & Bemak, 1998; Matsuoka, 1993). This group tended to be poorer, less educated, and subject to greater premigration trauma than the first wave (Chung et al., 1997). It has been suggested that the first wave, when compared to the second wave, experienced fewer postmigration adjustment problems due to the differences in the premigration experiences (Nguyen, 1982).

Longitudinal research on refugee children and adolescents is sparse (Sack, Chanrithy Him, & Dickason, 1999) despite the fact that 35% to 50% of the refugee population is estimated to have been under the age of 17 upon arrival in the United States (Huang, 1989). The few studies on refugee adolescents and children are limited in that they use clinical samples and/or recently arrived refugee children (e.g. Fry, 1985; Harding & Looney, 1977; Rousseau & Drapeau, 1998), and focus on youth at higher risk for maladjustments (e.g., Bemak & Greenberg, 1994; Felsman, Leong, Johnson, & Felsman, 1990; McKelvy, Webb, & Mao, 1993; Miller, 1998).

Little is known about the ongoing adjustment and mental health of young Vietnamese refugees given the lack of research and inconsistent findings. Some studies suggest that Vietnamese refugee adolescents are at high risk for the development of emotional distress including depression, psychotic episodes, and impaired social functioning due to their premigration traumatic experiences (e.g., Bemak & Greenberg, 1994; Charron & Ness, 1983; Nicassio, 1985; Rahe, Looney, Ward, Tung, & Liu, 1978). It is postulated that strong emotional family support helps refugee children adapt to their new environment (Harding & Looney, 1977; Huang, 1989), consistent with findings that social support and significant adults have a strong impact on Vietnamese refugee adolescents' psychosocial development (Charron & Ness, 1983; Dinh, Sarason, & Sarason, 1994; Gold, 1993; McAdoo, 1993).

Although studies clearly establish higher incidents of mental health problems for refugees (Kinzie, 1993; Weisaeth & Eitinger, 1993; Williams & Berry, 1991), there is an absence of research about the adaptation process and subsequent mental health of refugee adults who migrated as children. To provide effective mental health interventions with this population, it is essential to understand the migration and psychosocial adjustment experiences and examine this process as it affects mental health. Therefore, this study investigates the relationship between mental health practice and the long-term effects of psychosocial adjustment of two waves of Vietnamese refugees who migrated to the United States as children. By investigating two waves of refugees, this study examines diversity within the Vietnamese refugee population.

Acculturation is a major variable in the psychosocial adjustment process, so that understanding how one identifies and integrates bicultural models of adaptation is essential for generating healthy psychological outcomes (e.g., Bemak, 1989; Berry, 1986). Studies clearly document the relationship between acculturation and mental health (Bemak, 2000; Bemak & Chung, 2000) as well as identify social support as an important factor in psychosocial adjustment and mental health (e.g., Chung, Bemak, & Kagawa-Singer,1998; Pierce, Lakey, Sarason, & Sarason, 1997). Since understanding psychosocial postmigration adjustment issues is essential to provide culturally responsive interventions for the unique needs of refugees, this study examines three main variables of psychosocial adjustment: (1) acculturation, (2) social support, and (3) psychological distress. In reviewing the literature, the hypotheses of this study are (a) similar to the adult population, there will be a difference in the level of distress between the respondents of the first and second waves with the second wave reporting higher levels of distress than the first wave, (b) the first wave will report to be more acculturated than the second wave, (c) the first wave will also report to be more satisfied with their social support than the second wave, and (d) gender differences will be found in the level of acculturation, women will report greater acculturation than their male counterparts.

METHOD

Participants and Procedure

The data in this study were collected from 12 colleges in the Los Angeles and Orange County areas in California, including community colleges, California State Universities, and University of California schools. The respondents were comprised of 358 Vietnamese college students (191 males and 167 females) with the mean age of 21 years. Respondents were recruited from Vietnamese Student Associations and Asian American Studies courses at each college. The questionnaire was in English and administered to groups of approximately 15 respondents in a classroom setting, taking approximately 30 minutes to complete.

Respondents' year of arrival in the United States. ranges from 1971 to 1985 with approximately 30% of the sample arriving in 1975 and over 50% arriving between 1980 and1985. The sample is therefore divided into 2 groups. The first group (n = 105, 54 males and 51 females) consists of those who arrived before 1976 (range: 1971-1975) and is labeled the first wave. The second group (n = 253,137 males and 116 females) is comprised of those who arrived after 1979 (range: 1980-1985) and labeled the second wave. The mean age for the first wave is 20.55 and 20.53 for the second wave. Differences were found in the age of arrival in the United States, with 85% of the first wave arriving under the age of 6 years old compared to 6% of the second wave. Thirty-three percent of the second wave arrived at ages of between 7 and 10, and 44% arrived in at ages of between 11 and 15. Seventy percent the second wave and 45% of the first wave were in refugee camps prior to resettlement in the United States. The parents in the first wave were more highly educated (father's education: 32% high school, 66% college; mother's education: 45% high school, 47% college) than the parents of the second wave (father's education: 23% high school, 61% college, mother's education: 43% high school, 37% college).

Measures

The dependent measures consisted of the Hopkins Symptom Checklist-21 (HSCL-21) (Green, Walkey, McCormick, & Taylor, 1988), a revised version of the Suinn-Lew Self Identify and Acculturation Scale (SL-ASIA) (Suinn, Rickard-Figueroa, Lew, & Vigil, 1987), and the Social Support Questionnaire (SSQ) (Sarason, Levine, Basham, & Sarason, 1983).

The HSCL-21 is derived from the original Hopkins Symptom Checklist, which is a 58-item, five-point scale, self-report symptom-rating inventory (Derogatis, Lipman, Rickels, Uhlenhuth, & Covi, 1974). The 21 items were obtained by using 3 independent samples including 404 clinical patients (Mattson, Williams, Rickels, Lipman, & Uhlenhuth, 1969), 224 nurses and 490 students (Green et al., 1988). All respondents completed the HSCL-58. Psychometric results conducted by Green et al. (1988) found a highly robust and stable three-factor structure with a high internal reliability. The factors were labeled General Feelings of Distress (e.g., "feeling lonely," " feeling that others do not understand you or are unsympathetic"), Somatic Distress (e.g., "pains in the lower part of your back," "weakness in parts of your body") and Performance Difficulty (e.g., "trouble concentrating," "having to do things very slowly in order to be sure you are doing them right"). Each factor is comprised of seven items. The 21 items are rated on a Likert-scale ranging from 1 = not at all to 4 = extremely. A high score indicates high levels of psychological distress. See Green et al. (1988) for a detailed description of the development of the HSCL-21.The HSCL-21 was also used in a recent study with 695 school principals, and the findings indicate a perfect replication of the three factors. The study also correlates the HSCL-21 with the GHQ-60 (General Health Questionnaire) and the findings indicated a high correlation between the two distress measures (Trenberth, Walkey, & Dewe, 1999).

To examine whether the items loaded on the same three factors for respondents in this study, principal component analyses and varimax rotations were performed. The results showed that the same items that made up the three separate factors loaded at least .35 or above. Overall the three factors were found to be internally consistent with alpha coefficients of .78, .82, and .81 respectively and .80 for total score.

The acculturation questionnaire used in the study was a revised version of the SL-ASIA (Suinn et al., 1987). The original SL-ASIA is a 21-item, self-report questionnaire and contains five factors. Concurrent validity of the SL-ASIA was established by correlating the scores of the SL-ASIA and demographic information that reflected levels of acculturation. For example, the longer a person attends school in the United States or the earlier the age of migration, the greater likelihood of higher levels of acculturation (Suinn, Ahuna, & Khoo, 1992). A high score indicates low levels of acculturation.

Only 15 out of the 21 items were used in the study. Items relating to generational identity were not included because these items had no relevance to the first generation sample. To further explore the degree of acculturation for this sample, two new items were included to examine language preference with parents and friends. Principal component analyses and varimax rotation were performed, and the results showed three factors. These factors were similar to the factors reported by Suinn et al. (1987). The first factor was labeled Language Preference, which accounted for 37% of the variance and consisted of six items that are associated with reading/writing and language preference (e.g., "what language do you speak with your friends?" what language do you prefer?"). Three items in this factor were also in the Suinn et al. (1987) reading/writing/cultural-preference factor. Factor two was labeled Ethnic Interaction, which accounted for 9% of the variance and consisted of six items related to ethnic interaction (e.g., "whom do you now associate with in the community?" "what is the ethnic origin of the friends and peers you had, as a child from 6 to 18?"). The items were also the same as those that loaded on Suinn et al.'s factor. The third factor was named Ethnic Identity and Pride which accounted for 8% of the variance and consisted of four items (e.g., "how do you identify yourself?" " if you consider yourself a member of the Asian group, how much pride do you have in this group?"). Again, the three items from this factor were in Suinn et al.'s affinity for ethnic identity and pride factor. One item relating to food preference was not included because of low loading (.10). The alpha coefficient alphas for each factor were .87, .74, and .45 respectively and .86 for total score. The low reliability for the third factor may be a reflection of the small number of items contained in that factor. (Results of the factor analyses for HSCL-21 and SL-ASIA are available from the authors.)

The Social Support Questionnaire, which is a highly reliable and valid measure of social support (Sarason et al., 1983), was also included in the study. The SSQ is a 27-item questionnaire, with each item asking a question requiring a two-part answer. The first part explores the number of people who can provide an individual with support (network size) and the second part examines the degree of satisfaction with the support (satisfaction with social support). Two sets of scores are given for each item. Since this study was focused only on the perceived satisfaction of social support and not the network size, only the satisfaction of the social support will be reported. Split-half and coefficient alpha reliabilities for the satisfaction scale were calculated. The split-half reliability coefficient was .93, and the coefficient alpha was .91. Item-total correlation for the satisfaction scale ranged from .63 to .80 with a mean of .71. Studies have found that the SSQ has internal consistency reliability, factor validity and construct validity among psychiatric and normal populations (e.g., Furukawa, Harai, Hirai, Kitamura, & Takahashi, 1999; Sarason & Sarason, 1994; Tardy, 1985).

Statistical Analyses

Analyses of variance (ANOVA) were performed to examine wave and gender differences as the main effect and also wave by gender interactions on the HSCL-21 to examine the level of distress, the SL-ASIA to explore the level of acculturation, and the SSQ to the investigate the level of social support. (See Table for the correlations of the HSCL-21, SL-ASIA, and SSQ.)

Table Correlations of Dependent Variables

           HSCL-21    SSQ

SSQ        .27(****)

SL-ASIA    .15(**)    .11(*)

Note: (*)p [is less than] .05, (**)p [is less than] .01, (***)p [is less than] .0001

RESULTS

Wave and gender were the two independent variables that were investigated with ANOVAs. The ANOVA results for the HSCL-21 total score indicate significant wave (F(3,329)=20.70, p [is less than] .0001) and gender (F(3,329) = 8.29, p [is less than] .001) differences. No significant difference was found for the W x G interaction. The second wave (M = 41.57, SD = 9.86) reported experiencing significantly higher distress than the first wave (M = 37.85, SD = 11.09). Women (M = 41.80, SD = 10.92) also reported experiencing higher distress than men (M = 38.96, SD = 10.04).

The ANOVA results for the acculturation total score indicated significant wave (F(3,329) = 118.79, p [is less than] .0001), gender (F(3,329) = 5.77, p [is less than] .02) and W x G (F(3.329) = 4.41, p [is less than] .04) differences. The first wave (M = 49.10, SD = 11.09) was significantly more acculturated than the second wave (M = 39.12, SD = 9.67). Women (M = 46.67, SD = 9.91) were also significantly more acculturated than their male counterparts (M = 41.61, SD = 11.49). The W x G interaction also revealed interesting results. No significant difference was found between males (M = 50.57, SD = 8.71) and females (M = 48.84, SD = 6.62) in the first wave while women in the second wave (M = 41.46, SD = 9.75) reported that they were significantly more acculturated than their male counterparts (M = 37.19, SD = 8.96, t = 2.74, p [is less than] .01). Men and women in the first wave displayed significantly more acculturation than women in the second wave (t = 2.51, p [is less than] .01). The greatest difference was between the men in the first wave who reported that they were significantly more acculturated than men in the second wave (t = 3.08, p [is less than] .0001).

According to the Suinn et al. (1987), the SL-ASIA item 15 "how would you rate yourself" gives the respondents an opportunity to identify themselves by completing a 10-point scale ranging from 0 = very Vietnamese to 9 = very American. The results showed that the first wave (M = 4.85, SD = 1.78) reported to be closer to the middle of the scale, that is, Vietnamese American or bicultural, whereas the second wave (M = 3.98, SD = 1.89, t = 5.31, p [is less than] .0001) was closer to the Vietnamese end of the scale. There were no significant differences between the women in the two waves. Again, there were significant differences between women (M = 4.31, SD = 181) and men (M = 3.69, SD = 1.94, t = 2.58, p [is less than] .01) in the second wave with women indicating closer proximity to the middle of the scale and the men closer to the Vietnamese end of the scale. The correlation of item 15 and the SL-ASIA total score was .71 (p [is less than] .0001).

The results of the ANOVA for social support revealed the only significant wave difference (F(3,329) = 9.37,p [is less than] .001). The first wave (M = 57.49, SD = 13.79) reported significantly more satisfaction with their social support network than the second wave (M = 53.81, SD = 14.39). No significant differences were found for gender and the wave x gender interaction.

DISCUSSION

The results of the exploratory study provide an important context for understanding how to effectively render mental health counseling for not only respective waves of Vietnamese refugees, but for refugees in general. This is consistent with the call for mental health professionals to become more actively involved in addressing the needs of refugees (Bemak & Chung, 2000; Chung & Bemak, 1998; Miller, 1998). The findings support the first hypothesis with the second wave Vietnamese students reporting more psychological distress than the first wave. The second and third hypotheses were also supported with the first wave reporting greater acculturation and satisfaction with their social support than the second wave. The fourth hypothesis was also supported with women reporting greater acculturation than men. However the wave x gender interaction showed that only the second wave women reporting greater acculturation than their male counterparts.

One possible explanation for the differences between the two groups in distress level, acculturation, and satisfaction in their social support was age of arrival in the United States. The first wave of refugee respondents in this study arrived when they were approximately 3 years old, compared to the second wave who were closer to 11 years old. Arriving in the United States and beginning acculturation at an early developmental stage when language and culture were at a formative period may have been a distinct advantage in psychosocial adjustment for the first wave. The second wave arrived in the United States during a later developmental period when social and cultural identity were particularly important, requiring rapid cultural adaptation and language acquisition. Hence migrating to a new culture at this period may be more distressful than to a younger cohort, which is consistent with other studies (e.g., Mena, Padilla, & Maldonado, 1987).

Given that the first wave has been in the United States longer than the second wave, it is not surprising to find the first wave identified themselves as more acculturated or bicultural, that is, Vietnamese American, whereas the second wave identified more with the Vietnamese culture. Interestingly, women generally reported being significantly more acculturated than their male counterparts. The gender differences within each wave are striking, with no significant gender differences in the first wave, but significant gender differences in the second wave, whereby women revealed significantly greater levels of acculturation than their male counterparts. This may be related to the women in the second wave identifying themselves as bicultural, compared to their male counterparts who identified themselves as more monocultural, or Vietnamese.

An explanation for gender differences may be the age of migration, with traditional gender roles for the second wave already being established. In response to these roles, second wave women may be more strongly motivated to acculturate due to the perceived greater autonomy of Western women. Second wave males do not acculturate at the same rate as their female counterparts, possibly wanting to maintain traditional gender roles, and thus causing a slower adaptation to the United States. Unlike the second wave, the first wave was less exposed to traditional gender roles given their early age of migration. This may coincide with the significantly higher levels of distress for women who may face more pronounced cultural differences in the acculturation process, particularly with regards to independence as they move from traditional social family and community networks into the new culture.

The second wave also reported that they were more dissatisfied with their social network than the first wave. Again, this may be attributed to the age of arrival (Ying, Akutsu, Zhang, & Huang, 1997). The first wave's arrival at a younger age may have helped them acculturate earlier and establish more effective social support networks. The second group's migration during their pre-adolescent years presented the challenge of learning English while adapting to a new culture, possibly causing greater problems adjusting and developing effective social support networks and subsequently more psychological distress.

It is important to note that the respondents in this study were not from a representative sample of young Vietnamese refugees since all the respondents were enrolled in college. Therefore the findings of this study may not be applicable to the general Vietnamese population. It is strongly recommended that future research focus on psychosocial adjustment and resultant psychological distress that may interfere with mental health and have application for mental health interventions. Additional longitudinal studies are also essential.

Implications for Mental Health Counseling

The findings of this study have relevance and implications for refugees in general. Understanding the dynamics of sociopolitical migration history and psychosocial adjustment of refugees as well as intergroup and gender differences is important for the development of sound theoretical and applied mental health interventions. Since this study showed that the second wave refugees were more distressed than their first wave counterparts and women were more distressed than men, cognizance of psychological distress and psychosocial adjustment as it relates to premigration age and gender is important. This calls for mental health professionals to concentrate on a balance of past history and present psychosocial adjustment issues, rather than solely focusing on postmigration problems, to ensure the resolution of premigration trauma. The finding that women are more distressed than men suggest the importance of exploring shifting gender roles in counseling. Issues such as independence, family relationships, shifting of traditional gender roles, changing family dynamics, and employment may be important in examining the psychological difficulties of refugee woman.

The first and the second wave women and first wave men also reported being bicultural and identified with being Vietnamese American rather than Vietnamese. The importance of ethnic identity in mental health has been well established (e.g., Cross, 1995; Helms, 1995), leading to the need for the mental health practitioner to focus on this as a key element in counseling. This may include exploring ethnic identity and examining personal and cultural identity as it relates to majority and minority culture and psychosocial adjustment.

Another finding in the study was that the second wave reported greater dissatisfaction with their social support networks, again, possibly related to the age of migration. Given the importance of social networks in Vietnamese society, it is essential that mental health professionals emphasize work with families and groups. There are three recommendations regarding this work.

The first recommendation is to provide therapeutic interventions for existing families and social networks that are dysfunctional. This requires interventions to assist in clarifying boundaries, changing roles, facilitating healthier communication patterns, and defining shifting responsibilities within the family, especially with the coalescence of pre- and postmigration cultures.

The second recommendation is to support and reinforce already established healthy social networks that go beyond the counseling interventions for troubled families and groups. This is particularly important for refugee families who have migrated and remain close, but may need support in strengthening their relationships during the postmigration phase. The third recommendation is to recreate social networks where there is an absence of family or friends in order to facilitate interpersonal awareness and experience. This requires establishing and encouraging participation in group counseling, extended family counseling, and other therapeutic group activities that underscore the importance of the findings in this study and the importance of social networks in the Vietnamese culture. Subsequently, interdependence emerges as a crucial theme that mental health professionals must address. In conclusion, the study suggests that it is important for mental health practitioners to investigate diversity within refugee populations and provides recommendations for mental health professionals working with these groups.

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Rita Chi-Ying Chung, Ph.D., is an assistant professor of Counselor Education and Fred Bemak, Ph.D., is a professor of Counselor Education. Both are with The Ohio State University. Sandra Wong, is a doctoral student at the University of California Berkeley.

This project was supported by an Institute of American Cultures Research Program in Ethnic Studies, University of California Los Angeles, and the National Institute of Mental Health (Grant RO1 MH44331). The authors wish to thank Nuynh-Nhu Le for her assistance in data gathering. Correspondence concerning this article should be addressed to: Rita Chi-Ying Chung, Counselor Education, School of Physical Activity and Educational Services, College of Education, The Ohio State University, 283 Arps Hall, Columbus, OH 43214. Email [e-mail].