Cross-cultural Medicine - NCBI

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* 800,000 Koreans

lived in the United States in 1990 * The presence in Korea of the US military spurred social change and encouraged migration to the United States * Korean immigrants are relatively homogeneous in class, occupation, and religious affiliation

Cross-cultural Medicine A Decade Later This, That, and the Other Managing Illness in a First-Generation Korean-American Family SOO-YOUNG CHIN, PhD, San Jose, California

The use of Western medicine and of holistic traditional medicine and healing rituals is common in Korean-American families with a chronically ill member. I present a case as an example of the complexity of health management in firstgeneration Korean-American immigrants. Immigration and acculturation issues, Confucian-related sociocultural and psychological factors, and the psychiatric diagnosis of Western specialists all elicited family conflict leading to emotional and physiologic distress. (Chin SY: This, that, and the other-Managing illness in a first-generation Korean-American family, In Cross-cultural Medicine-A Decade Later [Special Issue]. West J Med 1992 Sep; 157:305-309) In Korea attitudes toward healing medications and the underlying belief systems perpetuate a pluralistic approach to health care. These multiple approaches to health and illness are not mutually exclusive but often are used together for different purposes. Traditional herbal medicine or hanyak, embedded in Confucian notions, is used to create harmony in oneself in relation to a larger harmonious cosmology.1 It is viewed as a way of healing both the soul and the body, of treating both the "ultimate causation" (usually spiritual) and "proximal causation" (usually material) of illness. It is the healing system preferred by older Koreans.2 Another viable alternative is Western medicine, which alleviates symptoms, especially in emergencies like a broken leg and with problems that require technical expertise like surgical treatment. Western medicine and hanyak can be used alternately or concurrently.3 Shamanistic healing rituals are another healing practice invoked to deal with particularly "difficult-to-define" illnesses or to ward off the possibility of misfortune when spirits are thought to be restless. "pp7179) The case presented here was brought to my attention by a Western physician who was intrigued not only by the complexity of the case but also because translators were necessary for the large family meetings. I was not brought in to translate. As a bicultural, bilingual anthropologist, part of my fieldwork with the Korean-American community has entailed accompanying Korean elders to medical appointments. My function in such cases is to observe the group dynamics for the Western physicians and to provide additional information and possible insights into the situation. I present the case to illustrate these dynamics.

Report of a Case The patient, a 29-year-old single man, lived with his lower-middle-class immigrant family that had been in the San Francisco Bay Area since 1975. The father was in build-

ing maintenance, worked hard, and had managed to buy a four-bedroom home in the suburbs. A neuropsychiatrist reported that the patient was a sweet but psychotic epileptic man. He was referred from an epilepsy program because of episodes of irritability, psychotic ideation, and poor compliance with his pharmacologic regimen. The patient reportedly had little insight into his situation; his primary concern was shame over his lack of knowledge of the English language. Medical History The medical records indicated that the patient had enjoyed good health until June 1983, when at the age of 22 he underwent a surgical procedure for a urethral stricture. The operation itself was uncomplicated, but following the procedure, the patient was given a combination product containing sulfamethoxazole and trimethoprim and tonic-clonic seizure activity developed. Two months later, in August of 1983, he had an episode of status epilepticus resulting in a two-week admission to a hospital. The workup showed diffuse slowing on three separate electroencephalograms, but a computed tomographic head scan and a lumbar puncture showed no abnormalities. During this period, the patient was observed by staff to be "superstitious" and paranoid with a "delusion that he had been chosen by God." The epilepsy persisted. Four years later, in February 1987, a right temporal lobectomy was done in an attempt to rectify the condition, but it was not successful. According to a psychologist who had followed the case since 1983, there was no previous psychiatric history except for a neuropsychiatric evaluation in January 1987. The patient's verbal IQ was estimated at 77 and performance IQ at 70, after the intracarotid administration of amobarbital sodium to test for speech and memory. All tests were given in English, although it was noted that English was the patient's second language and that he had come to the United States from Korea at age 14.

From the Departments of Anthropology and Asian American Studies, College of Social Sciences, San Jose State University, San Jose, California. Reprint requests to Soo-Young Chin, PhD, Departments of Anthropology and Asian American Studies, San Jose State University, One Washington Sq, San Jose, CA 95192-01 13.

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Psychosocial History The patient was the only and therefore the first-born son in a family of four children. He had two older married sisters and one unmarried younger sister. He was born in Seoul, Korea, where he attended grade school and junior high school before moving to the United States. After leaving high school in the United States, he worked briefly at a gas station before the seizures forced him to give up work. There was no known history of childhood physical or sexual abuse. The patient's family shared a great concern over his well-being. Course of Illness September 1990. When I met the patient in September 1990 he had been living at home for the past seven years and had been unable to work. His younger sister, who also lived at home, reported that earlier in the year the patient believed that he could stop his seizures through mind control and ceased taking his medications. This led to a series of major motor seizures. The medical regimen at that time was 400 mg of phenytoin (Dilantin) per day and 45 mg of clorazepate dipotassium (Tranxene) per day. His medical records, however, indicated that he was intermittently noncompliant with this regimen. In my first interview, the patient reported having had one to two seizures a day, each preceded by an aura of buzzing noise in both ears. When this sensation came on, he said he felt calm and went either into the backyard or into the livingroom where he would lie down to have the seizure. If his mother was around, she provided him with a pillow. This was in contrast to prelobectomy episodes in which he had epigastric distress coupled with significant anxiety before the seizures.

The patient denied any episodes of violence directed at others. According to his medical records, however, he had struck a wall with his fist two years previously. His sisters also reported that after he had had several seizures, he became upset and violent and believed that people were "looking down on him." At these times, he also lost trust in his family. I was introduced to the patient by the neuropsychiatrist at his office. I was to observe and comment on a follow-up evaluation of the patient's condition and to make sure that he understood the content of this appointment. On meeting the patient I was struck by his inability to articulate well in Korean or English, as well as the lack of logic to his statements in both languages. The language difficulties were, in part, attributed to the lobectomy. How much of the patient's thought disorder predated the lobectomy was unclear. The patient was preoccupied by shame over his poor mastery of English, particularly compared with his three sisters. He said that he read all the time, trying to improve his English. Neither ofhis parents spoke much English. The patient said he felt sorry for his mother who was unable to leave home because of her inability to communicate in English. He mentioned that his younger sister "thinks she [is] too good for me, and she's better than me. She's always showing off. I don't like my sister." He talked about the family's plans for finding a spouse for his sister and that his parents were arranging for her to be married. He then mentioned that all of his Korean friends had gotten married and that he wanted to get married and have a normal life. On inquiring within the Korean community about the patient, I discovered that in 1979, just four years after migrat-

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ing to the United States, his family had taken him to the Korean community center for counseling. In 1981 he had been referred to the Korean community center through a program for juvenile delinquents. His Korean-American social worker reported the following: Oh yeah, I remember him. He was really messed up. He was a very confused kid, rebelling against his Korean parents. You know, embarrassed about his background and doing really bad things like stealing cars or something. It's really hard for kids to come here at his age and adjust. His mother is such a nice lady.. . . She did everything she could. We tried to help, but it got to be too much for us to handle. I wondered what happened to him.

It is important to note that the patient had behavioral problems and contact with Korean counseling before his contact with Western medicine. Western medicine was the last resort for this family. When I asked the social worker what the patient's mother did when she "did everything she could," the social worker recalled that the mother had gone first to fortune tellers to locate the source of her son's destructive and delinquent behavior. When that failed to abate his problems, she sought traditional herbal medicines that might soothe him. When those, too, failed to produce results (it is unclear whether this was because of noncompliance with the traditional herbal medical system), the mother went to the Korean community center for help. The patient's seizures began after these efforts at managing his behavior had not succeeded. Only then did the family decide to use the Western medical system. October 1990. In October, the mother admitted her son to a psychiatric hospital because the patient had become so despondent and aggressive that she feared for her life. The father was in Korea trying to finalize arrangements for their youngest daughter's marriage. After the father returned but before the patient was released, a meeting was held with the patient's three physicians-a neurosurgeon, a neuropsychiatrist, and a psychiatrist-a neuropsychologist, two social workers, the parents, the three sisters, and me. My role was largely to observe, to provide culturally sensitive commentary to the physicians, and to intervene only when it seemed absolutely necessary. The oldest daughter acted as the mediator and spokesperson for the family and the patient. Whenever the patient said anything, his sister would interpret what he said for the parents and for the Western health practitioners. I found this remarkable because the patient spoke in incomplete sentences that made no sense to me, but the sister was able to piece together his unfinished phrases and come out with a version of the story with which the patient seemed to concur. The sister and other family members seemed to be aware of his perceptions of the world and had learned to communicate with him. They had come to some understanding of the underlying logic of his thinking. It was unclear to me whether or not their interpretations were accurate or were a "cleaned up" version of the story for themselves or the physicians to minimize embarrassment and shame. According to the oldest sister, before the violent episode that resulted in the patient's admission to hospital, the family's chief fear was that he would have an epileptic episode when he left the house. They wished desperately to avoid the commotion associated with an ambulance and transport to a local hospital. The patient, however, had recently been much more agitated about being kept at home. The sister who lived at home mentioned that on several occasions the patient had sneaked up outside the window of her room while she was

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reading and repeatedly mouthed the words, "I'm going to get you." He had also yelled at his mother. Because the father was out of the country, the mother and daughters decided it would be safer for everyone if the patient were hospitalized. During the meeting, the eldest daughter indicated that in Korea the patient had been a good student, athletic, and popular with his peers. When he first came to the United States, he tried hard to fit in. Both of the older sisters said that of all the children in the family, their brother seemed to adjust the fastest initially. At first his friends were all EuropeanAmericans and he seemed popular with the girls. Later, however, he fell in with a bad crowd of rebellious KoreanAmerican teenagers. The family pinpoints this period as the beginning of the patient's behavioral difficulties, which have continued to be a problem ever since. The attending physician raised some concerns about the patient's release from the hospital because he had locked himself in a bathroom and drunk a bottle of povidone-iodine and a bottle of hydrogen peroxide. When the patient was asked by Western physicians if he was trying to kill himself, he denied the incident had even happened. The attending psychiatrist said that a translator had been called in to talk with the patient and reported that the patient had wanted to kill himself. The eldest sister said that the patient had told her that when he was in the hospital he did not believe he had legs; he thought his legs had been amputated (perhaps a way of saying he felt he had no standing in his family and was shamed by this?). She reported that the patient used the word "chugesso" and asked what was the point of living if he did not have legs? The phrases chugesso or chugetta are commonly used among Koreans. They do not carry the threat of suicide. During my initial interview with the patient, he had indeed repeatedly said to himself, chugesso, meaning "I could die [of mortification]," referring to his shame about his condition. The sister suggested that the patient spoke in an unusual manner and did not make much sense to others and that a poor interpretation or translation of his speech patterns may have led to the physicians' misunderstanding the seriousness of the situation. To the physicians, chugesso ["I could die"] could have been seen as a death threat or a sign of suicidal intent rather than as an expression of shame or embarrassment. The sister went on to state calmly that the patient did have violent outbursts and that the family was used to dealing with them. Furthermore, although he had drunk the cleaning chemicals, it did not mean that he had tried to kill himself. The family believed that he simply did not know what he was doing at the time. (According to one psychologist, the patient seems to have had violent outbursts during his seizures about once every six months.) The sister also noted that in the past-as in this instance-many of the patient's statements had been interpreted out of context. She asked me to verify her interpretation of the meaning of the term "chugesso," which I did. It was not clear, however, if the family wanted to downplay the incident because it caused them to lose face or if that was, indeed, how they perceived the situation. During the discussion of the patient's alleged suicide threat by the Western practitioners and the patient's sister, the rest of the family spoke among themselves about the father's recent visit to Korea and his unsatisfactory visits with various jom]eangis (fortune tellers) about the patient's problems. The father had finally found a mansin or shaman who seemed to make sense. Consultation with the shaman revealed that

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the grave site of the father's parents was inauspicious and because of that the patient might be "possessed." Great concern was expressed by the family about locating the right geomancer to find the appropriate space for a reburial and about the associated costs. In Korean society, when divination is used to diagnose sources of mental or chronic illness, it is not uncommon to blame supernatural beings, mainly dead ancestors or other gods and demons.'7 8 "Possession" is not the only or even the most common way that ancestors, spirits, and ghosts are believed to influence a living person, but it is one possible explanation for the types of seizures and violent fits that the patient was experiencing.5 9 The father, who is the eldest son in his family, thought that this might be a valid issue because he had neglected his parents' grave sites for some time. The final decision of the family meeting was that the patient would go home and the mother would control his medications. In conversations in Korean among the family members, it was revealed that the father had brought back four types oftraditional herbal medications for his son to take in addition to the medications prescribed by the physician because the Western medicine alone was not "curing" his son. The family clearly thought that the use of both Western and traditional Korean medicine was not in any way harmful. At this point I intervened and asked the sister to explain to the physicians what herbs they were going to give the patient. She insisted that they were "just herbs" and not harmful. Two of the physicians seemed aware of the family's occasional use of traditional herbal medicine but not of the full extent of it. When the physicians realized that the family had been medicating the patient on their own, they asked the family to bring in the traditional herbal medicine for analysis so that possible drug interactions could be evaluated. Neither the family nor the practitioners followed through on this request. The family seemed to want to do everything possible to help the patient, including making plans to move the grave site of the father's parents. After the meeting, the family confided to me that all of the members were emotionally exhausted from dealing with the patient's chronic problems. The parents said that they were physically exhausted as well. The mother, once an active member of a Korean church, had stopped socializing in the community. The entire family was feeling ostracized by the rest of the Korean community because of the patient, who first was delinquent and then an epileptic psychotic. The two older sisters also mentioned that they continually had to take time off work to deal with the ongoing crises and that they both had conflicts with their husbands because of the attention their brother required. November 1990. In November, a second violent episode occurred in the household. The patient came into the kitchen one evening, grabbed a knife, cut the phone cord, and entreated his parents to commit a joint suicide. When they refused, he threatened to kill both of them first and then himself. Both parents got down on their knees and pleaded with him for their lives. When the patient started to cry the mother managed to run out of the kitchen and call the police. The patient was admitted to the hospital involuntarily for 72 hours of psychiatric observation. After this episode, the parents refused to take the patient home, so the hospital stay was extended two weeks until placement could be arranged. Another family meeting was held with the three physicians, the neuropsychologist, the

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three social workers, the entire family, a visiting aunt, myself, and a health care worker. Family members finally admitted being unsure of what the patient meant when he talked and confessed that they were now afraid of his violent outbursts. Responsibility for the patient was shifted to local health care officials. Although placement in a residential care unit was difficult because the family lived in a different county from where he was hospitalized, this was eventually

accomplished. April 1992. A year and a half after discharge from the hospital to a residential care unit, the patient got upset when an attendant gave him

his medication because he said he was

being given "too many pills." He shouted at the attendant, pushed her down to the floor, and lifted a heavy paper punch as if to attack her. As a consequence, the patient was moved to the psychiatric ward of a hospital. At the time of this writing, three residential options were being considered: return the patient to the residental care unit, admit him to Napa (California) State Hospital for life, or put him in a locked psychiatric unit until an alternative living arrangement could be found. The family had arranged to move the grave site of the father's parents in the summer of 1992. Geomancers were consulted in planning the move of the graves. The youngest daughter had returned to Korea to try and find a man who would marry her despite the shame and stigma of having a chronically mentally ill brother. The mother was near collapse and had withdrawn from the wider Korean community, which was increasingly uneasy about the shame the patient was bringing to them all. The father was disengaged. The eldest sister reported that he was having memory problems, although he claimed that he was not but was just "sick to death" of dealing with his son.

Discussion The problems of this family are far from resolved. Given the severity of the patient's condition, there seem to be few options for this family. Consultation with the mansin (shaman) in Korea brought some relief to the older generation, who were still waiting to see what would happen when the ancestral grave site was resituated with the help of a geomancer. " Only after discovering the inauspiciousness of the grave sites was the family able to relinquish some of the responsibility for the patient's care and allow Western health care professionals to manage the case. This does not mean that alternative modes of healing have been abandoned, only that while the family waited for the relocation of the grave site, they would leave his care to local authorities. This particular case is complex because of the various levels on which the patient's illness was perceived, presented, and treated. The family elected to use all of the alternatives available to them to help their son, but there was a difference between the attitudes of the parents and those of the three sisters. Although the sisters complied with their parents' wishes and did not describe the other forms of treatment they were using for the Western health-care professionals until I insisted, the women repeatedly entreated their parents to "listen to the doctors" and to try to use just one form of medication. After I asked the eldest sister to tell the physicians about the alternative healing practices that they were using, she asked one of the physicians why it might be a problem to use both traditional herbal and Western medicine concurrently since traditional medicine was "just herbs." The sisters were unwilling to translate the conversation be-

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tween their parents and aunt about the mansin's (shaman's) assessment of the patient's disorder. They appeared uncomfortable and mentioned the inauspicious grave sites to the Western physicians only because the father insisted. Other contributing factors to management of a firstgeneration Korean-American patient are the Confucianrelated sociocultural and psychological factors that may elicit conflict and lead to emotional and physiologic disorders in a family member." 112 The patient was the first and only son, and expectations for a son far exceed those for daughters in both work and family responsibilities. There is pressure for the eldest son to make something of himself, to provide an heir to the family line, and eventually to take care of his parents. The patient's entry into the United States at age 14 was not easy, and his delinquency in his late teens and early 20s attests to a period of rebellion against this new society and against his parents who represented traditional Korea. During my initial interview with the patient, he expressed great sorrow that all of his Korean friends (with whom he used to steal cars) had left him about three years before when they had gotten married and started their own families and households. This was the final severing of any sense of community that he had found in the United States. It also heightened his differences from his peers and his inability to perform adequately the roles expected of him. Birth sequence reflects ordering of life events.11 A failure to live up to these standards is a source of conflict in both the patient and his family. When the two older sisters married and had children, the patient was not particularly upset because it is expected that siblings marry in birth order. He seemed to trust the eldest sister and was indifferent to the second-born sister. The patient felt tremendous rage, however, toward the youngest sister who lived at home with him. Being the elder brother, he thought that he should have been better than this sibling. The sister, however, was managing much better than he was and was still seeking a husband in Korea at the time of this writing. Finally, the effects of migration on families and on the mental health of their members cannot be ignored. The necessary restructuring of values and ways of life are accompanied by a tremendous acculturation stress that may affect families differently.'3' 5 Adaptation to the United States was not easy for this family. The family was well aware that US society was somewhat hostile toward non-European Americans. Talking among themselves in the family sessions, the parents expressed sentiments about the difficulties of living here. The patient's three sisters concurred with these sentiments. The two older sisters married first-generation Korean men, and the younger sister intended to marry a man in Korea because she wished to live there. The entire family agreed that they did not want to be noticed publicly. The fact that the son had seizures that brought attention to them created great distress for the family. There was tremendous shame associated with the patient's chronic mental health problems. The family has tried to keep the problems in the family. Several issues are raised by this particular case. First, with the influx of non-Western immigrants to the United States, there is a need for medical professionals here to recognize and understand non-Western medical systems and attitudes toward health and illness. Many healing resources-traditional and Western-are available to firstgeneration Korean-American families. In a psychiatric context that encourages the family to reveal details of a patient's

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disorder because it will help the family deal with the problems, the family in this case tried to cover up the extent of their family member's illness to save face. Furthermore, this family placed its hopes on traditional modes of healing. Traditional and Western medical practitioners need to work together in designing treatments for patients and families who are not of European-American descent. Second, the issue of overmedication is real. The patient reported here might have been overmedicated inadvertently because of the multiple treatments his family sought for him. Traditional Southeast Asian and Asian medicines might be "just herbs," but herbs can have great potency and cause drug interactions when used in combination with Western medications. 16.17 It behooves health professionals to follow up more closely when traditional medicines are being used. In negotiating the Western medical system in the United States, first-generation immigrants need a cultural interpreter, not just a translator. * Often a translator merely explains words from one language to another without attending to the underlying belief system of the culture. As in this case, many misunderstandings can ensue. Finally, this case study brings up the compounding factors of migration and acculturation stress; both have bearing upon the initial symptoms of mental and physiologic disorders.14 There has been a shift toward Western medicine among Korean Americans, particularly among young cohorts of first-generation Korean Americans who have been educated and spent most of their lives in the United States. The biomedical approach is not the sole system of treatment but is used in combination with hanyak and other types of healing rituals, which vary greatly with age, education, and socioeconomic status. According to Pang, health and illness practices in first-generation Korean Americans can be most accurately described as pluralistic in nature.2 This pluralistic nature can add to intergenerational conflict and family disintegration when family members with different views toward *See also L. Haffner, "Translation Is Not Enough-Interpreting in Setting," on pages 255-259 of this issue.

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health and illness are forced to deal with problems such as chronic mental illness. Given this multifocal approach to health and illness and the different views about health practices that can exist within one family, it is critical for Western health professionals to work with or at least understand beliefs about health practices of other cultures so that healing can occur. REFERENCES 1. Kim Y, Sich D: A study on traditional healing techniques and illness behavior in a rural Korean township. Anthropol Stud (Seoul) 1977; 3:77-111 2. Pang KY: The practice of traditional medicine in Washington, DC. Soc Sci Med 1989; 28:875-884 3. Landy D: Role adaptation: Traditional curers under the impact of Western medicine, In Logan MH (Ed): Health and the Human Condition: Perspectives on Medical Anthropology. North Scituate, Mass, Duxbury Press, 1978, pp 217-242 4. Kendall L: Confucian patriarchs and spirited women, chap 2, Shamans, Housewives and Other Restless Spirits. Honolulu, Hawaii, University of Hawaii Press, 1985, pp 23-38 5. Kim KI: Shamanistic healing ceremonies in Korea. Korea J (Seoul) 1973; 4:4147 6. Janelli RL, Janelli DY: Ancestor Worship and Korean Society. Stanford, Calif, Stanford University Press, 1982 7. Chang CK: An introduction to Korean shamanism, chap 4, In Guisso RWI, Yu CS (Eds): Shamanism: The Spirit World of Korea. Berkeley, Calif, Asian Humanities Press, 1988, pp 30-51 8. Kendall L: Wood imps, ghosts, and other noxious influences, chap 5, Shamans, Housewives, and Other Restless Spirits. Honolulu, Hawaii, University of Hawaii Press, 1985, pp 86-1 12 9. Kim KI, Won HT: Traditional concept and folk-treatment of mental illness among the rural peoples-Part I, Folk-psychiatry in Korea. Neuropsychiatry (Seoul) 1972; 11:85-98 10. Janelli D: Ancestors, women, and the Korean family, In Slote WH (Ed): The Psycho-dynamics of the Confucian Family: Past and Present. Seoul, Korea, International Cultural Society of Korea, 1986, pp 197-215 11. Lee KK: Confucian tradition in the contemporary Korean family, In Slote WJ (Ed): The Psycho-dynamics of the Confucian Family: Past and Present. Seoul, Korea, International Cultural Society of Korea, 1986, pp 3-22 12. Rhi BY: Confucianism and mental health in Korea, In Slote WH (Ed): The Psycho-dynamics of the Confucian Family: Past and Present. Seoul, Korea, International Cultural Society of Korea, 1986, pp 249-272 13. Sluzki CE: Migration and family conflict. Fam Process 1979; 18:379-390 14. Berry JB, Kim U: Acculturation and mental health, In Dasen PR, Berry JW, Sartorius N (Eds): Health and Cross-cultural Psychology: Towards Applications. Newbury Park, Calif, Sage, 1987, pp 207-234 15. Kiefer C, Bliwise N, Kim S: Adjustment problems of Korean American elderly. Gerontologist 1985; 26:477-482 16. Mitchell MF: Popular medical concepts in Jamaica and their impact on drug use. West J Med 1983; 139:841-847 [37-43] 17. Haak H, Hardon A: Indigenised pharmaceuticals in developing countries: Widely used, widely neglected. Lancet 1988; 2:620-621