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Hwabyung and Depressive Symptoms
among Korean Immigrants
Jonghyun Lee PhD, LCSW
a
a
School of Social Work, Bridgewater State University, Bridgewater,
Massachusetts, USA
Published online: 12 Feb 2015.
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To cite this article: Jonghyun Lee PhD, LCSW (2015) Hwabyung and Depressive Symptoms among
Korean Immigrants, Social Work in Mental Health, 13:2, 159-185, DOI: 10.1080/15332985.2013.812538
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Social Work in Mental Health, 13:159–185, 2015
Copyright © Taylor & Francis Group, LLC
ISSN: 1533-2985 print/1533-2993 online
DOI: 10.1080/15332985.2013.812538
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Hwabyung and Depressive Symptoms among
Korean Immigrants
JONGHYUN LEE, PhD, LCSW
School of Social Work, Bridgewater State University, Bridgewater, Massachusetts, USA
This article describes the findings from a study that examined
the psychological ramifications of immigration experiences among
Koreans in the United States using hwabyung and depressive symptoms. Data collected from an anonymous survey of 242 voluntary
participants were analyzed using Pearson’s correlation coefficient
( r), and hierarchical multiple regression ( R2 ). The findings demonstrated the statistically significant correlation between hwabyung
and depressive symptoms. Also found was the important role of
coping resources in explaining both hwabyung and depressive
symptoms among Korean immigrants. Additionally, the findings
suggest that having a graduate school education in the United
Sates, receiving money from Korea, and being a woman were
found to be significantly related to hwabyung symptoms. However,
no factors related to individual characteristics appeared to have a
significant impact on depressive symptoms. Based on the findings,
the implications for practice are discussed.
KEYWORDS Hwabyung, depression, culture-bound syndromes,
acculturation, stress and coping, Korean immigrants
INTRODUCTION
The strikingly high level of depressive symptoms among Korean immigrants
in the United States is disconcerting. Subsequent to the first epidemiological
study of Korean immigrants in the United States (Kuo, 1984), succeeding
studies have reported notably high scores on the Center for Epidemiological
Studies of Depression (CES-D) scale ranging from 12.6 to 17.6 (Choi, 1997;
Address correspondence to Jonghyun Lee, PhD, LCSW, School of Social Work,
Bridgewater State University, Burrill Office Complex, Room 102Z, 95 Burrill Avenue,
Bridgewater, MA 02325. E-mail: [email protected]
159
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160
J. Lee
Hurh & Kim, 1990a; Kim, Han, Shin, Kim, & Lee, 2005; Kim, Seo, & Cain,
2010; Koh, 1998; Oh, Koeske, & Sales, 2002; Shin, Han, & Kim, 2007). These
findings show extremely elevated levels of depressive symptoms found
among Korean immigrants in comparison to not only those of the general population in the United States, but also the national sample in Korea.
The CES-D scores among the general population in the United States ranges
from 7.94 to 9.25 while the score for the national sample in Korea is 10.57
(Kim et al., 2010). The difficulties involved in the immigration experiences
might have increased the psychological vulnerability of Korean immigrants,
resulting in heightened levels of depressive symptoms (Park & Bernstein,
2008).
A number of studies identified various factors affecting the changes
in depressive symptoms among Korean immigrants (Bernstein, Park, Shin,
Cho, & Park, 2011; Jang, Chiriboga, Kim, & Rhew, 2010; Kim et al., 2005;
Oh, 2007; Noh, Kaspar, & Wickrama, 2007; Shin, D’Antonio, Son, Kim, &
Park, 2011). In addition to personal characteristics including gender, age,
education, marital status, or employment status, the depressive symptoms
of Korean immigrants are linked to their English proficiency, length of residency in the United States, and affiliations with their ethnic community.
The increased levels of depressive symptoms are observed when Korean
immigrants encounter both subtle and explicit forms of discrimination and
prejudice against them. The reasons for immigration to the United States as
well as whether they have plans for re-immigration to Korea are found to
be other critical indicators of depressive symptoms. These findings demonstrate that multiple factors are in play and are related to the psychological
well-being of Korean immigrants.
Despite their useful contributions, explaining the psychological
ramifications of immigration through depressive symptoms alone may have
limited applicability. Such an approach does not take account of the crosscultural variations in psychological symptoms experienced by different ethnic
groups (Arnault & Kim, 2008; Kanazawa, White, & Hampson, 2007; Kuo,
1984). Culture shapes all illness behaviors and every psychological distress
is culture-bound (Simon & Hughes, 1993). For Koreans, hwabyung symptoms might be a culturally appropriate way to assess the psychological
ramifications of their immigration experiences.
Hwabyung is an indigenous psychiatric illness commonly found in
Korean culture. The literal meaning of hwabyung is “fire illness,” which
is synonymously used with “anger syndrome.” Another Korean term
wol-hwabyung, meaning suffocating anger illness, is also used interchangeably with hwabyung. Koreans believe that chronic distress can cause the
onset of hwabyung, which manifests itself mainly through somatic symptoms (Min et al., 2009). According to Lin and colleagues’ (1992), almost 12%
of Korean immigrants suffer from hwabyung. Their finding demonstrates that
the prevalence of hwabyung among Koreans in the United States is much
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Hwabyung and Depressive Symptoms
161
higher than the 4.1% prevalence rate found in Korea (Min, 2009). However,
little is known about hwabyung in the United States.
The purpose of this article is to describe the findings from a study
that examined the psychological ramifications of immigration experiences
among Koreans in the United States using hwabyung and depressive symptoms. Specifically, the following two questions were explored: (1) What is
the relationship between hwabyung and depressive symptoms? (2) What is
the relative importance of coping resources and individual characteristics on
hwabyung and depressive symptoms? Based on the findings, implications for
practice are discussed.
PSYCHOLOGICAL RAMIFICATIONS OF IMMIGRATION
Acculturation, Stress, and Coping
The major theoretical tenets frequently employed in the studies of immigration are acculturation, stress, and coping. Immigration requires individuals
to adjust to their new cultural environment and social system. The term
acculturation refers to the multiple, drastic, and permanent changes in
lifestyles or behaviors that take place through reciprocal interactions between
individual immigrants and the conditions of their new environment (Berry,
2005; Castro, 2007). When the demand to change exceeds the immigrants’
capability of adapting to their new environment, it can increase their
psychological vulnerability.
According to Lazarus and Folkman (1984), stress is the relationship
between the person and the environment that is appraised as a threat to
the well-being of that person. Immigration is often considered a stressful life
event that has negative mental health consequences (Berry, 2006; Noh et al.,
2007). Due to their separation from a familiar environment, immigrants can
feel a sense of loss. While adjusting to the conditions of their new environment, they have to learn a new language and social norms. Also, immigrants
may have to accept jobs that are not compatible to their educational or professional experiences attained in their countries of origin. Immigrants may
feel a sense of rejection when they encounter hostility from the members
of their host countries. These difficulties can heighten their psychological
vulnerability.
Coping is a wide range of attempts that an individual employs to avoid
or lessen the impact of stressful life events (Amodeo, Griffin, Fassler, Clay, &
Ellis, 2007; Lazarus & Folkman, 1984). Immigrants may try to cope with the
difficulties involved in immigration by calling on psychological resources or
social support. A sense of self-esteem is counted as a psychological coping
resource (Rosenberg, 1979), whereas social support includes the tangible
or emotional assistance provided by family, friends, or neighbors (Matthieu
& Ivanoff, 2006). The findings of previous studies demonstrate the critical
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J. Lee
role of social support and self-esteem in lessening the psychological symptoms among Korean immigrants (Han, Kim, Lee, Pistulka, & Kim, 2007; Kim,
2006). When examining the immigration experience of Koreans, their ability
to overcome difficulties involved in their immigration experiences should not
be overlooked.
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Culture and Psychological Distress
Kleinman (1988), a medical anthropologist, explains psychological distress as
a cultural construction that is created through dialectic interactions between
individuals and their environments. Culture shapes individuals’ perceptions,
experiences, expression of psychological distress and the ways they cope
with its symptoms. Social workers must consider the potential influence of
culture on illness behaviors of Korean immigrants.
While assessing the psychological impacts of acculturation, Kim and
colleagues (2010) observed that Korean immigrants are reluctant to express
positive feelings such as happiness and satisfaction. The collectivistic cultural
norms of Korea encourage reciprocity and interrelatedness among individuals through humbleness and self-effacement. To maintain harmonious
stability in daily life, restraining expression of emotion is an essential quality that each individual has to cultivate. Due to their cultural practice that
inhibits expressing positive feelings, Koreans tend to display higher levels
of depressive symptoms (Choi, 2004; Jang, Kwag, & Chiriboga, 2010; Park &
Bernstein, 2008).
A Culture-Bound Syndrome Hwabyung
To emphasize the importance of culture in understanding the psychological
symptoms, the fourth edition of the Diagnostic Statistical Manual of Mental
Disorders (DSM-IV) (1994) lists 25 culture-bound syndromes. It defines
culture-bound syndromes as “locally specific patterns of aberrant behaviors
and troubling experiences that may or may not be linked to a particular
DSM-IV category” (American Psychiatric Association [APA], p. 844). In the
DSM-IV, hwabyung is listed as a Korean culture-bound syndrome caused by
a prolonged suppression of anger.
Social stratification appears to be closely related to hwabyung.
Aneshensel (1992) elucidates the source of psychological distress in relation to the social structure that excludes certain groups of people from full
participation in society. The heightened levels of psychological vulnerability
is a predictable consequence of a discriminatory social system (Jang et al.,
2010; Noh et al., 2007; Tang, 2007).
Indeed, a number of empirical findings support this theoretical notion
that hwabyung can be caused by social stratification (Kim, 2004, 2006).
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163
Existing studies constantly indicate that hwabyung especially affects women
due to the patriarchal norms of Korean culture (Khim & Lee, 2003; Min, 2009;
Park, Kim, Schwartz-Barcott, & Kim, 2002). Life adversities of Korean women,
including issues related to conjugal relationships, child rearing, and unfair
criticism from their in-laws are known to be significantly associated with
hwabyung. In this regard, hwabyung can be conceived as a psychological
manifestation provoked by Korean women’s marginalized social position.
In the case of Korean men, their inability to fulfill a socially prescribed
masculine role of the family provider may provoke hwabyung symptoms. For
instance, men usually comprise less than 10% of total clients at hwabyung
clinics in Korea. After the serious financial crisis of 1997 that severely affected
the Korean economy, this number increased to 30% of total clients (Kim,
2006). Rather than a gender-specific psychiatric distress, hwabyung should
be seen as a resultant of various challenges in life including economic
stratification.
In the United States, both Korean men and women are at greater risk
of being afflicted with hwabyung. Although very little is known about
hwabyung in the United States, existing research not only confirms the
generally held assumption that hwabyung is fairly common among Korean
immigrants, but it also predicts that in the United States we will see even
higher prevalence rates than found in Korea (Lin et al., 1992). The difficulties involved in the immigration experience increase the vulnerability of
Koreans to hwabyung symptoms.
Medical Explanations of Hwabyung
According to traditional Korean medicine, hwabyung is caused by a neurotic
fire (hwa) that is developed by suffering extreme distress for a prolonged
time (Lee, 2013). It explains that hwabyung occurs from an imbalance
between yin (negative elements) and yang (positive elements) caused by
chronic stress. Traditional Korean medical theory explains that the neurotic
fire (hwa) can accumulate in the heart, liver, stomach, head, and chest.
When neurotic fire becomes over-activated due to a deficiency of yin, it
can provoke hwabyung (Min, 2009).
Western psychology, in contrast, explains that the origin of hwabyung is
an incomplete suppression of negative emotion projected on the body. Hwa
is a complex psychological state composed of various emotions including
frustration, anxiety, mortification, anger, apprehension, and disappointment
along with physical manifestations (Lee, 2013, Min, 2009; Min & Suh, 2010).
Hwabyung develops through the accumulation of external stresses that provokes a buildup of hwa over a long period of time (Park, 2004). Although
each medical approach tries to explain hwabyung according to its own
theoretical perspective, both the Western and traditional Korean medical
explanations see accumulated stress as the major source of hwabyung.
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J. Lee
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Symptoms Related to Hwabyung
The primary symptoms of hwabyung include a stuffy feeling in the chest,
frequent sighing, palpitations, fatigue, hot or cold sensations, heaviness of
the head, insomnia, localized or generalized aches and pains, dry mouth,
indigestion, anorexia, dizziness, nausea, constipation, blurred vision, cold
and hot sensations in the body, face, eyes, or mouth, frequent urination,
and cold sweats. Other symptoms of hwabyung include anger, pessimism,
anxiety, loneliness, guilt, irritability, loss of motivation for life, sense of
suffocation, exhaustion, and feelings of helplessness and hopelessness (Min,
2009; Min et al., 2009). Since hwabyung encompasses multiple layers of
symptoms, it is linked to various DSM diagnoses including major depression,
anxiety disorder, somatization disorder, panic disorder, posttraumatic stress
disorder, phobic disorder, and obsessive-compulsive disorders (Min, 2008;
Min & Suh, 2010).
Information relevant to the prognosis of hwabyung is rare and often
inconsistent. As it is known to be a chronic illness, people generally suffer
from hwabyung longer than 10 years before they seek out psychiatric intervention (Min, 2004a). According to Min (2008), people with hwabyung experience various forms of negative emotions and physiological symptoms. Also,
depending on the personality traits of each individual and the defense mechanism that he or she employs, individuals may develop symptoms related to
depression at one time, but at other times, they experience anxiety and
somatization-related symptoms. Because of this, people with hwabyung are
frequently diagnosed with two or more DSM disorders including depression,
anxiety, and somatization disorders (Min & Suh, 2010; Park, 2004).
Symptoms Related to Depression
In comparison to hwabyung, which manifests primarily through physiological symptoms, the symptoms of major depression are characterized by
depressed mood (feelings of emptiness or sadness) and diminished interests
or pleasure in daily activities (APA, 1994). Other symptoms of major depression listed in the DSM include significant changes in weight (either loss or
gain); sleep disturbance; loss of energy; psychomotor agitation or retardation;
sense of worthlessness or inappropriate guilt; diminished concentration; and
recurrent thoughts of death or suicide. The severity and frequency of these
depressive symptoms and lengths of their course vary from individual to
individual (National Institute of Mental Health [NIMH], 2011).
Genetic disposition, chemical imbalances in the brain, and environmental factors such as stressful life events are known to contribute to
the development of depressive symptoms. Depression often coexists with
chronic illness, substance abuse, and anxiety. It also develops when a
person’s life is out of balance due to adverse life experiences (Hayleya,
Hwabyung and Depressive Symptoms
165
Poultera, Meralib, & Anismana, 2005; Edwards et al., 2010). Due to their
experience of depressive symptoms, individuals may feel exhausted and
overwhelmed, which in turn, hinders their ability to carry out daily activities
(NIMH, 2011).
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Diagnostic Issues Related to Hwabyung
Neither the DSM nor the International Classification of Diseases (ICD) provides diagnostic criteria for hwabyung. There has been controversy over
whether hwabyung could be seen as a separate illness distinctive to Korean
culture apart from psychiatric disorders listed in the DSM, especially major
depression. Some argued that the establishment of a separate diagnostic
entity such as a Korean culture-bound syndrome might not be necessary
since hwabyung can be a culturally patterned expression of psychiatric
suffering arising from major depression since they share similar symptom
characteristics (Lin, 1983; Lin et al, 1992; Park, Kim, Kang, & Kim, 2001; Park
et al., 2002).
On the contrary, more recent studies suggest that hwabyung is a culturally specific psychiatric illness (Min, 2009; Min et al., 2009; Park, 2004).
Although certain hwabyung symptoms are frequently comorbid with those
of other psychiatric disorders found in the DSM such as depression, many
argue that hwabyung has its own distinctive cultural traits and symptom
characteristics including anger and haan, a complex emotional state that
involves mixed feelings of sorrow, endurance, and regret, along with feelings of hatred and revenge (Min, 2009). However, the debate about whether
hwabyung is a culture-bound syndrome unique to Koreans or a psychiatric disorder listed in the DSM remains controversial and needs further
investigation. Continued rigorous cross-cultural research will enhance our
understanding of the similarities and differences between hwabyung and
depressive symptoms.
SIGNIFICANCE OF THE STUDY
The significance of this study is to examine the psychological ramifications of immigration experiences among Koreans living in the United States
using a culture-bound syndrome hwabyung and depressive symptoms. More
specifically, this is the first study that examines the relationship between
hwabyung and depressive symptoms from a sample of Korean immigrants in
the United States. In addition, this study examined the impacts of social support, self-esteem, and differences in individual characteristics on the changes
in hwabyung and depressive symptoms. The findings of this study will
advance cross-cultural psychiatric insights of social workers that can promote
the psychological well-being of Korean immigrants.
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J. Lee
METHOD
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Data Collection Procedure
This was a cross-sectional study that employed a non-probability sample of
242 Korean immigrant men and women who were at least 20 years old.
In the current study, Korean immigrants are defined as those who consider
the United States their permanent domicile regardless of their current immigration status. The participants in this study had to be first-generation adult
Korean immigrants, both male and female, who immigrated to the United
States after the age of 18. Previous studies indicate that the immigration
experience among those who immigrated before the age of 16 is substantially
different from that of adult immigrants (Noh & Avison, 1996; Oh et al., 2002;
Yu, Choe, & Han, 2002). Additionally, participants had to be able to read
and write Korean in order to complete the Korean language questionnaire.
The non-probability sampling method was chosen because it is relatively easy to implement, cost effective, and less time consuming. Korean
immigrants constitute less than 1% of the general population in the United
States and reside in different geographical locations across the country. Thus,
non-probability sampling was an appropriate method to achieve the intended
purpose of the study.
The participants were recruited from a total of five educational,
religious, and other social institutions serving Korean immigrants located in a
metropolitan area of the East Coast of the United States. It has been reported
that most Korean immigrants are affiliated with at least one or two ethnic
organizations and more than 70% of them are affiliated with religious institutions in their ethnic community (Min, 2010). Thus, local ethnic organizations
in the Korean immigrant community were appropriate settings to recruit
potential participants, representing diverse demographic characteristics in the
study.
Self-administered Korean language standardized questionnaires were
used for data collection. Also, an anonymous survey design was employed
in the current study. Koreans often do not overtly express their inner feelings or thoughts in public (Alford, 2000). By ensuring the participants’
anonymity, this study hoped to elicit direct and honest responses from the
participants. Additionally, when distributing the questionnaire, the participants were informed of the purpose and procedures of the study as well
as the voluntary nature of their participation. The approximate time needed
to complete the questionnaire was 30 minutes. A $10 gift certificate was
provided to the participants as a token of appreciation.
A total of 285 questionnaire packets were distributed to potential
participants. Among those, 251 questionnaires (88.07%) were returned.
Of those, 242 questionnaires (96.41%) were used for data analysis. Nine questionnaires were excluded because they contained minimal or no information,
or the participant’s age did not meet the criterion set by this study.
Hwabyung and Depressive Symptoms
167
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Individual Characteristics
Of the 242 adult Korean immigrants who participated in the study, slightly
more participants were women (n = 143, 59.1%) than men (n = 99;
40.9%), with a median age of 41 years. The median length of residence
in the United States was 10 years. The major reasons for the participants’
immigration to the United States were education for self (f = 74, 30.6%),
followed by marriage (f = 38, 15.7%) and education for children (f = 31,
12.8%). The majority lived with a spouse or partner (n = 212, 87.6%)
and almost all the participants had religious affiliations (n = 215; 88.8%).
Approximately half of the total participants own their own homes (n = 118;
48.8%) and almost three-quarters of them reported that their annual family
income exceeded $50,000. Some (f = 22; 9.1%) indicated that they send
money to their families in Korea on a regular basis. Interestingly, almost
as many (f = 19; 7.9%) reported that they received money on a regular
basis from family members in Korea. Regarding educational experiences,
225 (92.8%) participants had attained above a high school education in
Korea. Approximately half of the participants (n = 115, 47.5%) attained
formal education while living in the United States. Of the 115 participants, 78
(67.8%) had received a graduate school diploma in the United States. Of the
242 participants, the largest number of participants described themselves as
professionals (n = 74, 30.6%) followed by housewives (n = 56, 23.1%).
Women were more likely to be unemployed. Of the 52 (21.5%) participants
who were unemployed, 47 (90.4%) were women. Concerning their English
proficiency, only 36 (14.9%) participants reported having no difficulties in
using English. Others reported that their confidence in using English was
either moderate (f = 110, 45.5%) or they had difficulties in using it (f = 94,
38.8%). The individual Korean immigrant characteristics are summarized in
Table 1.
Standardized Instruments
All standardized instruments employed in the current study were Korean
language versions. The Hwabyung and Social Support scales were originally devised in Korean. For CES-D and Self-esteem scales, translated
versions were employed. To ensure the validity and reliability of the
instruments prepared for this study, and make it easier for participants to
answer questions, a reverse translation into Korean was conducted. These
instruments have adequate psychometric properties and have been widely
used in both Korea and the United States. Additionally, a pilot test was
conducted to detect potential problems related to data collection instruments and concerns that respondents may encounter while answering the
questions.
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J. Lee
TABLE 1 Demographic Characteristics
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Individual characteristics
Gender
Women
Men
Age
<30 years old
≥30 and ≤50
≥51
Unknown
Spouse/Partner
Yes
No
Type of Residence
Rent
Own home
Other
Family Income
≤ $50,000
>$50,000
Unknown
English Proficiency
Moderate or Good
Difficult
Unknown
Religious or Spiritual Affiliation
Yes
No
f
%
143
99
59.1
40.9
9
185
47
1
3.7
76.4
19.4
.4
212
30
87.6
12.4
119
118
5
49.2
48.8
2.1
56
180
6
23.1
74.4
2.5
146
94
2
60.4
38.8
.8
215
27
88.8
11.2
N = 242.
THE H WABYUNG SCALE (HS)
The HS was originally devised in Korean to assess personality and symptoms
related to hwabyung. It consists of two sub-scales that assess personality
and symptoms related to hwabyung (Kwon, Kim, Park, Lee, Min, & Kwon,
2008). Sixteen items of the HS measure personality and the other 15 items
measure symptoms related to hwabyung. In the current study, the 15-item
HB symptoms sub-scale is used to assess the psychological ramifications of
the immigration experiences among Koreans in the United States. The personality scale is excluded from the current study since it is less effective
in assessing symptoms related to hwabyung (Kwon et al., 2008). The HB
symptoms sub-scale is designed to measure emotional and somatic symptoms including “I feel deep anger at times” and “I have a burning sensation
in my chest.” The respondents are asked to answer each item on a 5-point
scale ranging from “0 = strongly disagree” to “4 = strongly agree.” The possible overall score ranged from 0 to 60. Higher scores indicate increased levels
of hwabyung symptoms. In the current study, Cronbach’s alpha reliability for
the symptom dimension of the HS was .92.
Hwabyung and Depressive Symptoms
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THE CENTER
FOR
169
EPIDEMIOLOGICAL STUDIES-DEPRESSION (CES-D) SCALE
The Korean version CES-D scale was employed in this study. The CES-D
scale was developed by Radloff (1977) to measure depressive symptoms for
research in the general population or to screen for high-risk populations.
This instrument is composed of a 20-item scale that involves four major
factors associated with depression including depressive affect, positive affect,
somatic and retarded activity, and interpersonal issues (Radloff, 1977). It uses
a 4-point scale ranging from “0 = rarely” to “3 = most of the time.” The
CES-D has four positively worded items. These positively worded items were
reverse scored in order to have higher scores representing higher depressivesymptoms. The possible overall score ranged from 0 to 60. Higher total
scores indicate higher levels of depressive symptoms. The Cronbach’s alpha
reliability of the CES-D scale based on the sample of this study was .89.
THE SOCIAL SUPPORT SCALE (SSS)
To assess perceived social support, this study employed the indirectly perceived social support section of the SSS devised in Korea by Park in 1985
(as cited in Choi 2006). In addition to the indirectly perceived social support
sub-scale, the original scales include situational support and direct support
sub-scales. This section of the SSS has been widely used in many studies conducted in Korea (Choi, 2006; Lee, 2005; Park, 2006). This 25-item scale covers
four different areas of support including emotional (7 items), informational
(6 items), material (6 items), and evaluative support (6 items). The following
are some items listed in the indirectly perceived social support sub-scale:
“The people around me always take good care of me with love,” and “The
people around me always offer me help as best as they can.” Respondents
are asked to answer each item on a 5-point scale (“1 = none of them are like
that” to “5 = all of them are like that”). The possible overall score ranged
from 25 to 125. The higher scores indicate receiving higher levels of social
support. The Cronbach’s alpha reliability for the indirectly perceived social
support section of the SSS based on the sample of this study was .97.
THE ROSENBERG SELF-ESTEEM SCALE (RSE)
In the current study, the 10-item Korean language version RSE scale was
employed. This scale was used to assess individual Korean immigrants’
sense of self-esteem based on their self-acceptance and self-worth statements
(Rosenberg, 1979). Each item was answered on a 4-point scale ranging from
“strongly disagree” to “strongly agree.” The possible overall score ranged
from 10 to 40. Higher overall scores indicate a greater sense of self-esteem.
The RSE has five negatively worded items that reflect an individual’s negative
sense of self. These negatively worded items were reverse scored in order to
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J. Lee
have higher scores represent higher self-esteem. The RSE has demonstrated
good reliability and validity and has been widely used across different ethnic
groups. The Cronbach’s alpha reliability of the Korean version of the RSE
scale based on the sample of this study was .86.
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FINDINGS
Preliminary Analyses
Descriptive analyses were performed to assess means, standard deviations,
and range of the hwabyung symptoms, depressive symptoms, social support,
and sense of self-esteem. The result of the data analysis shows that the mean
score of hwabyung symptoms was 12.01 (SD = 8.78) with a range from 0 to
47 (possible overall score: 0–60). The mean score of depressive symptoms,
on the other hand, was 10.60 (SD = 7.58) with a range from 0 and 44
(possible overall score: 0–60). Both mean scores of hwabyung symptoms
and depressive symptoms found in this study were lower than or similar to
the findings from most of the other studies conducted on Koreans in the
United States or Korea (Choi, 1997; Kim 2005; Koh, 1998; Kwon et al., 2008;
Oh et al., 2002).
In the case of coping resources, the mean score of social support was
90.29 (SD = 14.98). When considering the possible overall score ranged
from 25 to 125, the current mean score indicates above a mid-level of social
support. Additionally, the mean score of sense of self-esteem was 31.35
(SD = 4.97). The possible overall score ranged from 10 to 40. Similar to
social support, the current findings indicate above a mid-level for sense of
self-esteem. Table 2 summarizes the findings of the preliminary analyses.
Bivariate Analysis
Pearson’s correlation coefficients (r) were performed to determine the relationship between the hwabyung and depressive symptoms. The result of
the data analysis demonstrated a positive, moderate correlation between
hwabyung and depressive symptoms (r = .56; P < .001). This finding implies
TABLE 2 Means and Standard Deviations of Daily Functioning, Hwabyung Symptoms,
Depressive Symptoms, and Coping Resources
Hwabyung symptoms
Depressive symptoms
Social support
Self-esteem
N = 242.
M
SD
Range
n (%)
12.01
10.60
90.29
31.35
8.78
7.58
14.98
4.97
0–47
0–44
27–125
15–40
241 (99.59)
237 (97.93)
240 (99.17)
240 (99.17)
Hwabyung and Depressive Symptoms
171
that Korean immigrants with a higher level of hwabyung symptoms are more
likely to show a higher level of depressive symptoms.
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Multivariate Analysis
Two separate hierarchical multiple regression (R2 ) analyses were performed
utilizing three blocks to assess factors contributing to either hwabyung or
depressive symptoms. Sense of self-esteem was entered in the first block
followed by social support, which was entered in the second block. In the
third block, individual characteristics relevant to the demographic makeup,
participants’ relationship with Korea, and acculturation were entered. The
findings from previous studies consistently demonstrate the statistically
significant role of self-esteem and social support in explaining the level
of psychological symptoms (Kim, 2004; Park & Song-Bernstein, 2008; Shin
et al., 2007; Wu, Noh, Kaspar, & Schimmele, 2003). By entering sense of selfesteem and social support in the first two blocks, the importance of these
two coping resources in explaining hwabyung or depressive symptoms was
assessed separately from the individual characteristics of participants in the
present study.
In order to perform the data analysis, a number of variables related to
individual characteristics were dichotomized in the following manner:
1. Demographic information: gender (0 = men, 1 = women), live with a
partner (0 = no, 1 = yes), and owning a home (0 = no, 1 = yes).
2. Acculturation: thought about re-immigration back to Korea (0 = no,
1 = yes), English proficiency (0 = difficult, 1 = moderate or okay), and
using Korean at home (0 = no, 1 = yes).
3. Education: not attaining education in the United States (0 = not checked,
1 = checked) and acquiring a graduate school degree in the United States
(0 = not checked, 1 = checked).
4. Income: annual family income (0 = $50,000 or less, 1 = more than
$50,000), and receiving money from Korea (no = 0; yes = 1).
In the present study, language-related acculturation is measured by English
proficiency of participants and their use of Korean at home. As a more
recent immigrant group, Koreans often prefer to use their native language
while interacting with members of their own families and ethnic community
(Jeon, 2008, 2012). At the same time, approximately 77% of Korean immigrants use English as their primary language at work (Kim & Wolpin, 2008).
For Korean immigrants, the use of their own native language at home can
strengthen the interaction among family members, while their English proficiency may affect their overall functioning in other domains of everyday life
including employment (Jeon, 2010; Zhen, 2013). Because of this reason, it is
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172
J. Lee
speculated that English proficiency and use of Korean at home have different
psychological ramifications.
In regard to education, the previous findings demonstrate that Korean
immigrants who attained higher education in the United States show
significantly increased levels of acculturation to the host culture (Hurh & Kim,
1984; Oh et al., 2002). In the current study, almost half of the 242 participants
(n = 115, 47.5%) had attended school while living in the United States and
among those, slightly more than two-thirds (n = 78; 67.8%) received a graduate school diploma. Rather than relying on the level of overall educational
attainment, in the current study, the psychological effect of immigration was
assessed based on the education received in the United States.
The literature on Korean immigrants consistently report the difficulties
involved in collecting data relevant to their income (Johnson, 2000; Kwon,
2003). To increase participants’ responses in the current study, the annual
family income was collected by grouping it into several categories. For data
analysis, the annual family income was reorganized into two categories, over
or less than $50,000. According to the U.S. Census Bureau (2004) the median
annual family income of Korean immigrants was $47,624. Thus, an annual
income of $50,000 is an appropriate amount that assesses the economic
standing of Korean immigrant families.
FACTORS CONTRIBUTING
TO
H WABYUNG SYMPTOMS
Table 3 summarizes the findings of the hierarchical multiple regression (R2 )
analysis performed to assess factors contributing to hwabyung symptoms.
The findings demonstrate that, taken together, a sense of self-esteem, social
support, and individual characteristics explained 38% of the variance in
hwabyung symptoms (F(14, 208) = 223; p < .001). The incremental change
for each of the three blocks was also significant. Five independent variables
were found to be significantly related to hwabyung symptoms. Of these
factors, social support was the strongest predictor, which explains 18.49%
of the variance in hwabyung symptoms, followed by sense of self-esteem
(5.76%), having a graduate school education in the United States (4%),
receiving money from Korea (3.61%), and being a woman (2.25%).
FACTORS CONTRIBUTING
TO
DEPRESSIVE SYMPTOMS
Table 4 presents the findings of the hierarchical multiple regression (R2 )
analysis that assessed factors contributing to depressive symptoms. Taken
together, a sense of self-esteem, social support, and individual characteristics
explained 25% of the variance in depressive symptoms (F(14, 207) = 4.90;
p < .001). The incremental change for each of the three blocks was also
significant. Similar to hwabyung, social support and sense of self-esteem
Hwabyung and Depressive Symptoms
173
TABLE 3 Contributing Factors for the Changes in Hwabyung Symptoms
Hwabyung symptoms
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Predictors
SE
ß
Block 1
Sense of self-esteema
−.22∗∗∗
Block 2
Social supportb
−.41∗∗∗
Block 3
Individual characteristics
Age
Women
Living with a partner
Owning a home
Acculturation
Thought about re-immigration
English proficiency
Use Korean at home
Length of stay
Education
No education in the U.S.
Graduate school education in the U.S.
Income
Annual family income > $50,000
Receive money from Korea
Partial correlation
.11
−.24
R2 = .16
F = 43.39∗∗∗ (1, 221)
.03
−.43
R2 change =.12
F change = 36.79∗∗∗ (1, 220)
−.02
.13∗
.01
−.04
.08
1.07
1.60
1.10
−.02
.15
.02
−.05
.09
−.03
.11
−.03
1.06
1.14
1.26
.09
.11
−.03
.13
−.02
−.13
−.24∗∗
1.47
1.52
−.10
−.20
−.05
.16∗∗
1.27
−.06
1.91
.19
R2 change = .10
F change = 2.73∗∗ (12, 208)
List-wise method for missing data; List-wise method was chosen due to a relatively small amount of
decrease in sample size available for the data analysis
N = 223; ∗ p < .05, ∗∗ p < .01, ∗∗∗ p < .001.
Overall F(14, 208) = 9.16; p < .001.
a
Sense of Self-esteem: The Rosenberg Self-Esteem Scale.
b
Social Support: The Social Support Scale.
were significantly associated with depressive symptoms, explaining 7.84%
and 6.25%, respectively, of the variance in depressive symptoms. Unlike
hwabyung, however, no individual characteristics were significantly related
to depressive symptoms.
DISCUSSION AND PRACTICE IMPLICATIONS
The findings demonstrated relatively lower levels of hwabyung and depressive symptoms among the participants in the current study. Also demonstrated was the statistically significant correlation between hwabyung and
depressive symptoms. In addition, the findings highlight the important role
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J. Lee
TABLE 4 Contributing Factors for the Changes in Depressive Symptoms
Depressive symptoms
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Predictors
ß
SE
Partial correlation
Block 1
Sense of self-esteema
−.26∗∗∗
.11
−.25
R2 = 15
F = 38.13∗∗∗ (1, 220)
Block 2
Social supportb
−.28∗∗∗
.03
−.28
R 2 change =.05
F change = 12.92∗∗∗ (1, 219)
Block 3
Individual Characteristics
Demographic information
Age
Women
Living with a partner
Owning a home
Acculturation
Thought about re-immigration
English proficiency
Use Korean at home
Length of stay
Education
No education in the US
Graduate education in the US
Income
Annual family income > $50,000
Receive money from Korea
−.11
.01
−.09
−.03
−1.17
.11
−1.32
−.42
−.08
.01
−.09
−.03
−.06
.05
.02
−.07
−.99
.73
.36
−.71
−.07
.05
.03
−.05
.07
.01
.78
.12
.05
.01
−.02
.08
−.25
−.02
1.25
.09
R2 change = .05
F change = 1.24∗∗∗ (12, 207)
List-wise method for missing data; List-wise method was chosen due to a relatively small amount of
decrease in sample size available for the data analysis
N = 222; ∗∗∗ p < .001.
Overall F (14, 207) = 4.90; p<.001; Total R 2 = .249.
a
Sense of Self-esteem: The Rosenberg Self-Esteem Scale.
b
Social Support: The Social Support Scale.
of coping resources in explaining the changes in the levels of both hwabyung
and depressive symptoms among Korean immigrants. Among the variables
related to individual characteristics, education attained in the United States,
receiving financial support from Korea, and being women appear to have
significant impacts on hwabyung symptoms. In contrast, no factors related
to individual characteristics were found to have significant impacts on
depressive symptoms.
Levels of Hwabyung and Depressive Symptoms
In the current study, the mean score of hwabyung symptoms was 12.01. This
mean score was approximately six points lower than the findings from the
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Hwabyung and Depressive Symptoms
175
previous study conducted in Korea, which was 18.38 (Kwon et al., 2008).
This outcome may be because of the data collection method. Unlike the
current study conducted in a community setting, the previous study was
conducted in a clinical setting (Kwon et al., 2008). All participants were
women recruited through advertisement or individual contacts. Women often
show higher levels of psychiatric disorders in comparison to men (Mumford,
Minhas, Akhtar, Akhter, & Mubbashar, 2000). Thus the gender of the participants as well as the relatively small sample size (n = 53) might have
influenced the previous study’s outcome. In regard to the level of depressive
symptoms, the current finding (M = 10. 57) is similar to the national sample
in Korea (M = 10.60). Moreover, the level of depressive symptoms found
in the current study is notably lower than the findings of previous studies
conducted on Korean immigrants in the United States, which ranged from
12.6 to 17.6.
The relatively lower levels of hwabyung and depressive scores found
in the current study may be connected to the socioeconomic characteristics
of the research participants. Three-quarters (n = 180; 74.4%) of the participants reported that their family income exceeded $50,000 a year, and
approximately one third (n = 74, 30.6%) of the participants reported that
their annual family income was more than $100,000. Also, the participants in
this study may have a better sense of life gratification due to the extended
length of their residence in the United States. The median length of residency among the participants in the current study was 10 years. This means
that the study participants could readdress their earlier hardships through
improved economic conditions, language skills, and social interactions with
mainstream society (Hurh & Kim, 1990b; Kim, 2009). These positive experiences might result in an enhanced sense of psychological well-being among
the study participants.
In addition, a relatively lower level of hwabyung and depressive symptoms may stem from sampling issues. Using a non-probability sampling
method, this study collected the data from social institutions located in
the Korean ethnic community. Since these organizations become a source
of support for the immigrants who attend these institutions, participants
in the current study might have a strong sense of connectedness to other
members of their institutions. This sense of connectedness may become a
source of psychological well-being where they could find a sense of security,
belonging, comfort, ethnic pride, and social support (Yoon & Lee, 2010).
However, it has to be noted that the level of depressive symptoms found
in the current study is higher than those of the general population in the
United States ranging between 7.94 and 9.25. Despite their relatively advantageous circumstances in comparison to other Korean immigrants, difficulties
associated with the acculturation experience might have increased the level
of their depressive symptoms.
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Correlation Between Hwabyung and Depressive Symptoms
In the current study, the findings suggest that Korean immigrants who suffer
from higher levels of depressive symptoms may be more likely to experience
increased levels of hwabyung symptoms. This outcome has an important
clinical implication. Not only can hwabyung be comorbid with depression,
but social workers should give careful attention to the ways Koreans express
their psychological distress. Korean immigrants tend to underutilize mental health services. The conventional diagnostic criteria, such as depression,
do not often capture the ways they experience psychiatric symptoms (Lee,
Hanner, Cho, Han, & Kim, 2008; Park & Bernstein, 2008). This may be
why, when suffering from hwabyung, Koreans often seek help from physicians, traditional medicine, and folk healers rather than psychiatric help (Min,
2004b).
Min (2004b, 2008) identifies the differences in symptom characteristics
between hwabyung and depression. People with hwabyung frequently complained of symptoms that were not part of depressive symptoms. Hwabyung
can manifest itself through respiratory stuffiness, an epigastric discomfort, a
heat sensation, subjective anger, and palpitations. In addition, people with
hwabyung often express a unique Korean psychology called haan, “a feeling of inward frustration that is derived from a sense of resignation, defeat,
and nothingness” (Kim, 1999, pp. 126–127). Additionally, people suffer from
haan because of abuse, exploitation, discrimination, violence, or other forms
of social injustice that they have experienced without having resources to
rectify the wrong. It has to be noted that Koreans believe their experiences of oppression and social injustice cause hwabyung (Min, 2004b, 2009).
By noting unique symptom expressions, psychosocial stressors, and the traditional remedies for hwabyung, social workers can enhance their clients’
compliance with intervention plans, which will result in better therapeutic
outcomes.
In regard to psychiatric intervention of hwabyung, Min (2004b,
2009) introduces a number of psychosocial treatment modalities effective
for hwabyung including short-term based psychotherapy, and cognitivebehavioral therapy. The focus of these psychosocial treatments includes
somatic symptom reduction and management of anger. Additionally, the
combined use of antidepressants and antianxiety medicine is recommended
in treating hwabyung symptoms (Min, 2004b, 2009).
The Role of Coping Resources in Lessening Hwabyung and
Depressive Symptoms
The findings of the current study demonstrate that social support and
self-esteem will strengthen the ability of Korean immigrants to cope with
both hwabyung and depressive symptoms. Indeed, the buffering effects of
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177
social support and a sense of self-esteem on psychological symptoms were
observed by a number of previous studies conducted on Korean immigrants
(Choi, Stafford, Meininger, Roberts, & Smith, 2002; Park & Song-Bernstein,
2008; Shin, Han, & Kim, 2007).
Also, social workers must recognize the different impacts that these
coping resources have on hwabyung and depressive symptoms. Taken
together, social support and a sense of self-esteem explains 24.25% of variance in hwabyung symptoms. In contrast, these coping resources explain
only 14.09% of the variance in depressive symptoms. These findings suggest the important role that coping resources play in explaining hwabyung
symptoms in comparison to depression.
Social workers can foster social support systems of Korean immigrants
and their sense of self-esteem by being familiar with Korean culture. Their
ethnic community is where Korean immigrants find social support (Choi,
1997; Kim et al., 2005; Noh & Kasper, 2003). For instance, over 70% of
Korean immigrants are affiliated with churches in their ethnic community
(Hurh & Kim, 1990b). The Korean church enhances immigrants’ search for
the meanings of their uprooting and re-rooting experiences. The church is
an inclusive and accessible social institution regardless of sex, age, or socioeconomic status. It functions as a “reception center” for new immigrants by
providing needed assistance for their resettlement, including information and
counseling on employment, health care, and children’s education (Kim &
Grant, 1997). It also plays a role as an educational center where immigrants’ children can learn the Korean language, history, and culture. For
many Korean immigrants, their ethnic church becomes an extended family
where they find a sense of belonging, security, and comfort.
Economic Hardship, Being Women, Education, and Hwabyung
Symptoms
Economic deprivation appears to be closely related to hwabyung symptoms. When immigrating to the United States, Korean immigrants often
experience a downward economic slide. Their professional experiences
and educational backgrounds attained in Korea are not often recognized
(Kim, Conway-Turner, Sherif-Trask, & Woolfolk, 2006). More often than not,
Korean immigrants have to restart their careers while struggling with language barriers and limited financial means. At times, they may even have to
rely on financial support from their family members in Korea. Their experience of financial insecurity might manifest as heightened levels of hwabyung
symptoms. Indeed previous findings have shown increased levels of psychological symptoms among Korean immigrants who experienced difficulties in
meeting their daily economic needs (Choi, 2004; Jang et al., 2009; Kim, 2006;
Kim et al., 2005).
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Korean immigrant women appear to be especially vulnerable to
hwabyung due to their multiple role obligations as wage earners, mothers, and wives with limited resources (Min, 2001; Kim & Grant, 1997; Park,
2008; Park, Harrison, & Bailey, 2000; Shin & Shin, 1999; Um & Dancy,
1999). Because of racial and language barriers, they work as helpers at
restaurants, drycleaners, and grocery stores in their ethnic community. These
women become unpaid workers if their families have self-owned businesses.
At home, they are expected to maintain traditional role obligations by taking
full responsibility for household tasks and child rearing. They face increased
levels of marital conflict when they demand a more egalitarian-based conjugal relationship. As stress accumulates in their daily lives, it can be manifested
as heightened levels of hwabyung symptoms.
Previous findings show that Korean immigrant women develop an
increased level of positive sense of self by recognizing their contributions to
the well-being of the family (Lim, 1997). Creating programs for Korean immigrant couples to enhance their ability to share family obligations can help
Korean women overcome their struggle with multiple role obligations. Such
programs can promote emotional closeness and communication skills that
can reinforce harmonious relationships between Korean immigrant couples.
Having a graduate education in the United States appears to have a
positive mental health effect for Korean immigrants. While examining the
sociocultural adaptation patterns of Korean immigrants, Hurh and Kim (1984)
found a significantly higher level of acculturation among those with undergraduate or graduate degrees attained in the United States. Regardless of
their length of residency, these Korean immigrants show a higher degree
of social integration. Through their education, these Koreans enhance their
English proficiency and professional credentials, which enable them to find
better economic opportunities. Indeed, immigrants experience faster earning
growth as they acquire not only English proficiency but also professional
training (Park, 1999). Creating language and professional training programs
that are accessible, affordable, and flexible enough to accommodate the
needs of Korean immigrants can foster their ability to support family members. Such efforts can contribute to the psychological well-being of Korean
immigrants and their families.
LIMITATIONS OF THE STUDY AND SUGGESTIONS FOR FUTURE
STUDY
The current study has to be considered preliminary and several limitations
should be acknowledged. This study employed a cross-sectional design.
It did not measure the changes in hwabyung or depressive symptoms over
time nor did the data collected through this design allow for assessing cause
and effect. The sampling method and geographical specificity of the data
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179
collection sites are other areas of concern. Because of the convenience
sampling method and relatively small sample size, the generalizability of the
findings is open to question. By employing a more rigorous data collection
method, future studies should increase the size and variability of the sample, and consequently the generalizability of the findings. Another concern
is social desirability. This study was conducted using a self-administered
survey that had an inherent limitation such as the possibility of under or
over reporting due to response bias.
In the current study, a statistically significant correlation between
hwabyung and depressive symptoms was found. However, this finding may
not be sufficient in deciding whether hwabyung and depression are identical
psychiatric disorders. The previous studies report that hwabyung symptoms
can manifest without comorbid symptoms (Min, 2008; Min & Suh, 2010;
Min et al., 2009; Park 2004). For instance, based on a study conducted on
221 psychiatric patients in Korea, Son (2006) found that 15% of the respondents in the study were diagnosed only with hwabyung without having
any other co-occurring psychiatric distresses. In a more recent study, Min
and colleagues (2010) found a significant correlation between the symptom profile of hwabyung and anger, rather than depression. Further studies
need to be conducted to determine whether or not hwabyung is a culturally
patterned expression of psychiatric illness arising from major depression.
In addition, a number of studies found a statistically significant link
between racial discrimination and psychological distress (Jang et al., 2007;
Mossakowski, 2003; Noh et al., 2007; Yip, Gee, Takeuchi, 2008). Moreover,
Koreans believe that abuse, exploitation, discrimination, violence, and other
forms of social injustice may cause the onset of their hwabyung symptoms. However, in the current study, the link between hwabyung and social
injustice has not been assessed. This requires future investigation.
In the current study, no factors related to individual characteristics were
significantly associated with depressive symptoms. The differences in demographic characteristics of individual Korean immigrants and their level of
acculturation, educational attainment, and financial circumstances appear
not to predict the changes in depressive symptoms. Although these findings
might suggest the differences between hwabyung and depressive symptoms,
the influence of limited variability among samples and small sample size
might have contributed to such an outcome. Future studies should employ
a more rigorous data collection method. Such an effort could yield a clearer
understanding of the link between the individual characteristics of Korean
immigrants and their experiences of psychiatric symptoms.
CONCLUSION
The findings of the current study enhance the cross-cultural insights by
identifying not only the relationship between hwabyung and depressive
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symptoms, but also the relative importance of coping resources and individual characteristics on both hwabyung and depressive symptoms. Despite the
statistically significant correlation between hwabyung and depressive symptoms, the findings also highlight their differences. It appears that coping
resources play a much bigger role in explaining the changes in hwabyung
symptoms than depression. The findings of the current study demonstrate
that receiving financial assistance from family members or relatives in Korea,
or being women can increase the vulnerability of Korean immigrants to
hwabyung. On the contrary, those who attained graduate school education in the United States are less likely to experience heightened levels of
hwabyung symptoms. However, the findings of the current study demonstrate that no individual characteristics explain the changes in the level of
depressive symptoms.
Social workers must be aware of the importance of culture that shapes
not only individuals’ experiences with psychological symptoms, but also their
coping behaviors. Taking culture into account means “affirming, witnessing,
and engaging the illness in the embodied terms in which it is experienced”
(Kleinman, 1988, p. 24). By learning about the illness beliefs of Korean
immigrants and their coping behaviors, social workers can provide culturally
appropriate services that address the difficulties involved in their immigration
experiences, and the ability of Korean immigrants to overcome them.
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