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Hwabyung and Depressive Symptomsamong Korean ImmigrantsJonghyun Lee PhD, LCSWa

a School of Social Work, Bridgewater State University, Bridgewater,Massachusetts, USAPublished online: 12 Feb 2015.

To cite this article: Jonghyun Lee PhD, LCSW (2015) Hwabyung and Depressive Symptoms amongKorean 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, 2015Copyright © Taylor & Francis Group, LLCISSN: 1533-2985 print/1533-2993 onlineDOI: 10.1080/15332985.2013.812538

Hwabyung and Depressive Symptoms amongKorean Immigrants

JONGHYUN LEE, PhD, LCSWSchool of Social Work, Bridgewater State University, Bridgewater, Massachusetts, USA

This article describes the findings from a study that examinedthe psychological ramifications of immigration experiences amongKoreans in the United States using hwabyung and depressive symp-toms. Data collected from an anonymous survey of 242 voluntaryparticipants were analyzed using Pearson’s correlation coefficient( r), and hierarchical multiple regression (R2). The findings demon-strated the statistically significant correlation between hwabyungand depressive symptoms. Also found was the important role ofcoping resources in explaining both hwabyung and depressivesymptoms among Korean immigrants. Additionally, the findingssuggest that having a graduate school education in the UnitedSates, receiving money from Korea, and being a woman werefound to be significantly related to hwabyung symptoms. However,no factors related to individual characteristics appeared to have asignificant 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 immigrantsin the United States is disconcerting. Subsequent to the first epidemiologicalstudy of Korean immigrants in the United States (Kuo, 1984), succeedingstudies have reported notably high scores on the Center for EpidemiologicalStudies 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: jonghyun.lee@bridgew.edu

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Hurh & Kim, 1990a; Kim, Han, Shin, Kim, & Lee, 2005; Kim, Seo, & Cain,2010; Koh, 1998; Oh, Koeske, & Sales, 2002; Shin, Han, & Kim, 2007). Thesefindings show extremely elevated levels of depressive symptoms foundamong Korean immigrants in comparison to not only those of the gen-eral population in the United States, but also the national sample in Korea.The CES-D scores among the general population in the United States rangesfrom 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 experiencesmight 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 changesin 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 symptomsof Korean immigrants are linked to their English proficiency, length of res-idency in the United States, and affiliations with their ethnic community.The increased levels of depressive symptoms are observed when Koreanimmigrants encounter both subtle and explicit forms of discrimination andprejudice against them. The reasons for immigration to the United States aswell as whether they have plans for re-immigration to Korea are found tobe other critical indicators of depressive symptoms. These findings demon-strate that multiple factors are in play and are related to the psychologicalwell-being of Korean immigrants.

Despite their useful contributions, explaining the psychologicalramifications of immigration through depressive symptoms alone may havelimited applicability. Such an approach does not take account of the cross-cultural variations in psychological symptoms experienced by different ethnicgroups (Arnault & Kim, 2008; Kanazawa, White, & Hampson, 2007; Kuo,1984). Culture shapes all illness behaviors and every psychological distressis culture-bound (Simon & Hughes, 1993). For Koreans, hwabyung symp-toms might be a culturally appropriate way to assess the psychologicalramifications of their immigration experiences.

Hwabyung is an indigenous psychiatric illness commonly found inKorean culture. The literal meaning of hwabyung is “fire illness,” whichis synonymously used with “anger syndrome.” Another Korean termwol-hwabyung, meaning suffocating anger illness, is also used interchange-ably with hwabyung. Koreans believe that chronic distress can cause theonset of hwabyung, which manifests itself mainly through somatic symp-toms (Min et al., 2009). According to Lin and colleagues’ (1992), almost 12%of Korean immigrants suffer from hwabyung. Their finding demonstrates thatthe prevalence of hwabyung among Koreans in the United States is much

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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 studythat examined the psychological ramifications of immigration experiencesamong Koreans in the United States using hwabyung and depressive symp-toms. Specifically, the following two questions were explored: (1) What isthe relationship between hwabyung and depressive symptoms? (2) What isthe relative importance of coping resources and individual characteristics onhwabyung and depressive symptoms? Based on the findings, implications forpractice are discussed.

PSYCHOLOGICAL RAMIFICATIONS OF IMMIGRATION

Acculturation, Stress, and Coping

The major theoretical tenets frequently employed in the studies of immigra-tion are acculturation, stress, and coping. Immigration requires individualsto adjust to their new cultural environment and social system. The termacculturation refers to the multiple, drastic, and permanent changes inlifestyles or behaviors that take place through reciprocal interactions betweenindividual 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 theirpsychological vulnerability.

According to Lazarus and Folkman (1984), stress is the relationshipbetween the person and the environment that is appraised as a threat tothe well-being of that person. Immigration is often considered a stressful lifeevent that has negative mental health consequences (Berry, 2006; Noh et al.,2007). Due to their separation from a familiar environment, immigrants canfeel a sense of loss. While adjusting to the conditions of their new environ-ment, they have to learn a new language and social norms. Also, immigrantsmay have to accept jobs that are not compatible to their educational or pro-fessional experiences attained in their countries of origin. Immigrants mayfeel a sense of rejection when they encounter hostility from the membersof their host countries. These difficulties can heighten their psychologicalvulnerability.

Coping is a wide range of attempts that an individual employs to avoidor lessen the impact of stressful life events (Amodeo, Griffin, Fassler, Clay, &Ellis, 2007; Lazarus & Folkman, 1984). Immigrants may try to cope with thedifficulties involved in immigration by calling on psychological resources orsocial support. A sense of self-esteem is counted as a psychological copingresource (Rosenberg, 1979), whereas social support includes the tangibleor emotional assistance provided by family, friends, or neighbors (Matthieu& Ivanoff, 2006). The findings of previous studies demonstrate the critical

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role of social support and self-esteem in lessening the psychological symp-toms among Korean immigrants (Han, Kim, Lee, Pistulka, & Kim, 2007; Kim,2006). When examining the immigration experience of Koreans, their abilityto overcome difficulties involved in their immigration experiences should notbe overlooked.

Culture and Psychological Distress

Kleinman (1988), a medical anthropologist, explains psychological distress asa cultural construction that is created through dialectic interactions betweenindividuals and their environments. Culture shapes individuals’ perceptions,experiences, expression of psychological distress and the ways they copewith its symptoms. Social workers must consider the potential influence ofculture on illness behaviors of Korean immigrants.

While assessing the psychological impacts of acculturation, Kim andcolleagues (2010) observed that Korean immigrants are reluctant to expresspositive feelings such as happiness and satisfaction. The collectivistic culturalnorms of Korea encourage reciprocity and interrelatedness among indi-viduals through humbleness and self-effacement. To maintain harmoniousstability in daily life, restraining expression of emotion is an essential qual-ity that each individual has to cultivate. Due to their cultural practice thatinhibits expressing positive feelings, Koreans tend to display higher levelsof 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 psychologicalsymptoms, the fourth edition of the Diagnostic Statistical Manual of MentalDisorders (DSM-IV) (1994) lists 25 culture-bound syndromes. It definesculture-bound syndromes as “locally specific patterns of aberrant behaviorsand troubling experiences that may or may not be linked to a particularDSM-IV category” (American Psychiatric Association [APA], p. 844). In theDSM-IV, hwabyung is listed as a Korean culture-bound syndrome caused bya prolonged suppression of anger.

Social stratification appears to be closely related to hwabyung.Aneshensel (1992) elucidates the source of psychological distress in rela-tion to the social structure that excludes certain groups of people from fullparticipation in society. The heightened levels of psychological vulnerabilityis 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 notionthat hwabyung can be caused by social stratification (Kim, 2004, 2006).

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Existing studies constantly indicate that hwabyung especially affects womendue 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 unfaircriticism from their in-laws are known to be significantly associated withhwabyung. In this regard, hwabyung can be conceived as a psychologicalmanifestation provoked by Korean women’s marginalized social position.

In the case of Korean men, their inability to fulfill a socially prescribedmasculine role of the family provider may provoke hwabyung symptoms. Forinstance, men usually comprise less than 10% of total clients at hwabyungclinics in Korea. After the serious financial crisis of 1997 that severely affectedthe Korean economy, this number increased to 30% of total clients (Kim,2006). Rather than a gender-specific psychiatric distress, hwabyung shouldbe seen as a resultant of various challenges in life including economicstratification.

In the United States, both Korean men and women are at greater riskof being afflicted with hwabyung. Although very little is known abouthwabyung in the United States, existing research not only confirms thegenerally held assumption that hwabyung is fairly common among Koreanimmigrants, but it also predicts that in the United States we will see evenhigher prevalence rates than found in Korea (Lin et al., 1992). The diffi-culties involved in the immigration experience increase the vulnerability ofKoreans to hwabyung symptoms.

Medical Explanations of Hwabyung

According to traditional Korean medicine, hwabyung is caused by a neuroticfire (hwa) that is developed by suffering extreme distress for a prolongedtime (Lee, 2013). It explains that hwabyung occurs from an imbalancebetween yin (negative elements) and yang (positive elements) caused bychronic stress. Traditional Korean medical theory explains that the neuroticfire (hwa) can accumulate in the heart, liver, stomach, head, and chest.When neurotic fire becomes over-activated due to a deficiency of yin, itcan provoke hwabyung (Min, 2009).

Western psychology, in contrast, explains that the origin of hwabyung isan incomplete suppression of negative emotion projected on the body. Hwais a complex psychological state composed of various emotions includingfrustration, anxiety, mortification, anger, apprehension, and disappointmentalong with physical manifestations (Lee, 2013, Min, 2009; Min & Suh, 2010).Hwabyung develops through the accumulation of external stresses that pro-vokes a buildup of hwa over a long period of time (Park, 2004). Althougheach medical approach tries to explain hwabyung according to its owntheoretical perspective, both the Western and traditional Korean medicalexplanations see accumulated stress as the major source of hwabyung.

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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 ofthe head, insomnia, localized or generalized aches and pains, dry mouth,indigestion, anorexia, dizziness, nausea, constipation, blurred vision, coldand 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 ofsuffocation, exhaustion, and feelings of helplessness and hopelessness (Min,2009; Min et al., 2009). Since hwabyung encompasses multiple layers ofsymptoms, it is linked to various DSM diagnoses including major depression,anxiety disorder, somatization disorder, panic disorder, posttraumatic stressdisorder, phobic disorder, and obsessive-compulsive disorders (Min, 2008;Min & Suh, 2010).

Information relevant to the prognosis of hwabyung is rare and ofteninconsistent. As it is known to be a chronic illness, people generally sufferfrom hwabyung longer than 10 years before they seek out psychiatric inter-vention (Min, 2004a). According to Min (2008), people with hwabyung expe-rience various forms of negative emotions and physiological symptoms. Also,depending on the personality traits of each individual and the defense mech-anism that he or she employs, individuals may develop symptoms related todepression at one time, but at other times, they experience anxiety andsomatization-related symptoms. Because of this, people with hwabyung arefrequently 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 physio-logical symptoms, the symptoms of major depression are characterized bydepressed mood (feelings of emptiness or sadness) and diminished interestsor pleasure in daily activities (APA, 1994). Other symptoms of major depres-sion listed in the DSM include significant changes in weight (either loss orgain); sleep disturbance; loss of energy; psychomotor agitation or retardation;sense of worthlessness or inappropriate guilt; diminished concentration; andrecurrent thoughts of death or suicide. The severity and frequency of thesedepressive symptoms and lengths of their course vary from individual toindividual (National Institute of Mental Health [NIMH], 2011).

Genetic disposition, chemical imbalances in the brain, and environ-mental factors such as stressful life events are known to contribute tothe development of depressive symptoms. Depression often coexists withchronic illness, substance abuse, and anxiety. It also develops when aperson’s life is out of balance due to adverse life experiences (Hayleya,

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Poultera, Meralib, & Anismana, 2005; Edwards et al., 2010). Due to theirexperience of depressive symptoms, individuals may feel exhausted andoverwhelmed, which in turn, hinders their ability to carry out daily activities(NIMH, 2011).

Diagnostic Issues Related to Hwabyung

Neither the DSM nor the International Classification of Diseases (ICD) pro-vides diagnostic criteria for hwabyung. There has been controversy overwhether hwabyung could be seen as a separate illness distinctive to Koreanculture apart from psychiatric disorders listed in the DSM, especially majordepression. Some argued that the establishment of a separate diagnosticentity such as a Korean culture-bound syndrome might not be necessarysince hwabyung can be a culturally patterned expression of psychiatricsuffering arising from major depression since they share similar symptomcharacteristics (Lin, 1983; Lin et al, 1992; Park, Kim, Kang, & Kim, 2001; Parket al., 2002).

On the contrary, more recent studies suggest that hwabyung is a cul-turally specific psychiatric illness (Min, 2009; Min et al., 2009; Park, 2004).Although certain hwabyung symptoms are frequently comorbid with thoseof other psychiatric disorders found in the DSM such as depression, manyargue that hwabyung has its own distinctive cultural traits and symptomcharacteristics including anger and haan, a complex emotional state thatinvolves mixed feelings of sorrow, endurance, and regret, along with feel-ings of hatred and revenge (Min, 2009). However, the debate about whetherhwabyung is a culture-bound syndrome unique to Koreans or a psychi-atric disorder listed in the DSM remains controversial and needs furtherinvestigation. Continued rigorous cross-cultural research will enhance ourunderstanding of the similarities and differences between hwabyung anddepressive symptoms.

SIGNIFICANCE OF THE STUDY

The significance of this study is to examine the psychological ramifica-tions of immigration experiences among Koreans living in the United Statesusing a culture-bound syndrome hwabyung and depressive symptoms. Morespecifically, this is the first study that examines the relationship betweenhwabyung and depressive symptoms from a sample of Korean immigrants inthe United States. In addition, this study examined the impacts of social sup-port, self-esteem, and differences in individual characteristics on the changesin hwabyung and depressive symptoms. The findings of this study willadvance cross-cultural psychiatric insights of social workers that can promotethe psychological well-being of Korean immigrants.

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METHOD

Data Collection Procedure

This was a cross-sectional study that employed a non-probability sample of242 Korean immigrant men and women who were at least 20 years old.In the current study, Korean immigrants are defined as those who considerthe United States their permanent domicile regardless of their current immi-gration status. The participants in this study had to be first-generation adultKorean immigrants, both male and female, who immigrated to the UnitedStates after the age of 18. Previous studies indicate that the immigrationexperience among those who immigrated before the age of 16 is substantiallydifferent from that of adult immigrants (Noh & Avison, 1996; Oh et al., 2002;Yu, Choe, & Han, 2002). Additionally, participants had to be able to readand write Korean in order to complete the Korean language questionnaire.

The non-probability sampling method was chosen because it is rela-tively easy to implement, cost effective, and less time consuming. Koreanimmigrants constitute less than 1% of the general population in the UnitedStates and reside in different geographical locations across the country. Thus,non-probability sampling was an appropriate method to achieve the intendedpurpose of the study.

The participants were recruited from a total of five educational,religious, and other social institutions serving Korean immigrants located in ametropolitan area of the East Coast of the United States. It has been reportedthat most Korean immigrants are affiliated with at least one or two ethnicorganizations and more than 70% of them are affiliated with religious institu-tions in their ethnic community (Min, 2010). Thus, local ethnic organizationsin the Korean immigrant community were appropriate settings to recruitpotential participants, representing diverse demographic characteristics in thestudy.

Self-administered Korean language standardized questionnaires wereused for data collection. Also, an anonymous survey design was employedin the current study. Koreans often do not overtly express their inner feel-ings or thoughts in public (Alford, 2000). By ensuring the participants’anonymity, this study hoped to elicit direct and honest responses from theparticipants. Additionally, when distributing the questionnaire, the partici-pants were informed of the purpose and procedures of the study as wellas the voluntary nature of their participation. The approximate time neededto complete the questionnaire was 30 minutes. A $10 gift certificate wasprovided to the participants as a token of appreciation.

A total of 285 questionnaire packets were distributed to potentialparticipants. Among those, 251 questionnaires (88.07%) were returned.Of those, 242 questionnaires (96.41%) were used for data analysis. Nine ques-tionnaires were excluded because they contained minimal or no information,or the participant’s age did not meet the criterion set by this study.

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Individual Characteristics

Of the 242 adult Korean immigrants who participated in the study, slightlymore participants were women (n = 143, 59.1%) than men (n = 99;40.9%), with a median age of 41 years. The median length of residencein 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 familyincome exceeded $50,000. Some (f = 22; 9.1%) indicated that they sendmoney to their families in Korea on a regular basis. Interestingly, almostas many (f = 19; 7.9%) reported that they received money on a regularbasis from family members in Korea. Regarding educational experiences,225 (92.8%) participants had attained above a high school education inKorea. Approximately half of the participants (n = 115, 47.5%) attainedformal 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 the242 participants, the largest number of participants described themselves asprofessionals (n = 74, 30.6%) followed by housewives (n = 56, 23.1%).Women were more likely to be unemployed. Of the 52 (21.5%) participantswho were unemployed, 47 (90.4%) were women. Concerning their Englishproficiency, only 36 (14.9%) participants reported having no difficulties inusing English. Others reported that their confidence in using English waseither moderate (f = 110, 45.5%) or they had difficulties in using it (f = 94,38.8%). The individual Korean immigrant characteristics are summarized inTable 1.

Standardized Instruments

All standardized instruments employed in the current study were Koreanlanguage versions. The Hwabyung and Social Support scales were orig-inally devised in Korean. For CES-D and Self-esteem scales, translatedversions were employed. To ensure the validity and reliability of theinstruments prepared for this study, and make it easier for participants toanswer questions, a reverse translation into Korean was conducted. Theseinstruments have adequate psychometric properties and have been widelyused in both Korea and the United States. Additionally, a pilot test wasconducted to detect potential problems related to data collection instru-ments and concerns that respondents may encounter while answering thequestions.

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TABLE 1 Demographic Characteristics

Individual characteristics f %

GenderWomen 143 59.1Men 99 40.9

Age<30 years old 9 3.7≥30 and ≤50 185 76.4≥51 47 19.4Unknown 1 .4

Spouse/PartnerYes 212 87.6No 30 12.4

Type of ResidenceRent 119 49.2Own home 118 48.8Other 5 2.1

Family Income≤ $50,000 56 23.1>$50,000 180 74.4Unknown 6 2.5

English ProficiencyModerate or Good 146 60.4Difficult 94 38.8Unknown 2 .8

Religious or Spiritual AffiliationYes 215 88.8No 27 11.2

N = 242.

THE HWABYUNG SCALE (HS)

The HS was originally devised in Korean to assess personality and symptomsrelated to hwabyung. It consists of two sub-scales that assess personalityand symptoms related to hwabyung (Kwon, Kim, Park, Lee, Min, & Kwon,2008). Sixteen items of the HS measure personality and the other 15 itemsmeasure symptoms related to hwabyung. In the current study, the 15-itemHB symptoms sub-scale is used to assess the psychological ramifications ofthe immigration experiences among Koreans in the United States. The per-sonality scale is excluded from the current study since it is less effectivein assessing symptoms related to hwabyung (Kwon et al., 2008). The HBsymptoms sub-scale is designed to measure emotional and somatic symp-toms including “I feel deep anger at times” and “I have a burning sensationin my chest.” The respondents are asked to answer each item on a 5-pointscale ranging from “0 = strongly disagree” to “4 = strongly agree.” The possi-ble overall score ranged from 0 to 60. Higher scores indicate increased levelsof hwabyung symptoms. In the current study, Cronbach’s alpha reliability forthe symptom dimension of the HS was .92.

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THE CENTER FOR EPIDEMIOLOGICAL STUDIES-DEPRESSION (CES-D) SCALE

The Korean version CES-D scale was employed in this study. The CES-Dscale was developed by Radloff (1977) to measure depressive symptoms forresearch in the general population or to screen for high-risk populations.This instrument is composed of a 20-item scale that involves four majorfactors associated with depression including depressive affect, positive affect,somatic and retarded activity, and interpersonal issues (Radloff, 1977). It usesa 4-point scale ranging from “0 = rarely” to “3 = most of the time.” TheCES-D has four positively worded items. These positively worded items werereverse scored in order to have higher scores representing higher depressive-symptoms. The possible overall score ranged from 0 to 60. Higher totalscores indicate higher levels of depressive symptoms. The Cronbach’s alphareliability 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 per-ceived 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 supportsub-scale, the original scales include situational support and direct supportsub-scales. This section of the SSS has been widely used in many studies con-ducted in Korea (Choi, 2006; Lee, 2005; Park, 2006). This 25-item scale coversfour different areas of support including emotional (7 items), informational(6 items), material (6 items), and evaluative support (6 items). The followingare some items listed in the indirectly perceived social support sub-scale:“The people around me always take good care of me with love,” and “Thepeople around me always offer me help as best as they can.” Respondentsare asked to answer each item on a 5-point scale (“1 = none of them are likethat” to “5 = all of them are like that”). The possible overall score rangedfrom 25 to 125. The higher scores indicate receiving higher levels of socialsupport. The Cronbach’s alpha reliability for the indirectly perceived socialsupport 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 wasemployed. 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 rangedfrom 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 negativesense of self. These negatively worded items were reverse scored in order to

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have higher scores represent higher self-esteem. The RSE has demonstratedgood reliability and validity and has been widely used across different ethnicgroups. The Cronbach’s alpha reliability of the Korean version of the RSEscale based on the sample of this study was .86.

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 meanscore of hwabyung symptoms was 12.01 (SD = 8.78) with a range from 0 to47 (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 symptomsand depressive symptoms found in this study were lower than or similar tothe findings from most of the other studies conducted on Koreans in theUnited 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 was90.29 (SD = 14.98). When considering the possible overall score rangedfrom 25 to 125, the current mean score indicates above a mid-level of socialsupport. 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 tosocial support, the current findings indicate above a mid-level for sense ofself-esteem. Table 2 summarizes the findings of the preliminary analyses.

Bivariate Analysis

Pearson’s correlation coefficients (r) were performed to determine the rela-tionship between the hwabyung and depressive symptoms. The result ofthe data analysis demonstrated a positive, moderate correlation betweenhwabyung 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

M SD Range n (%)

Hwabyung symptoms 12.01 8.78 0–47 241 (99.59)Depressive symptoms 10.60 7.58 0–44 237 (97.93)Social support 90.29 14.98 27–125 240 (99.17)Self-esteem 31.35 4.97 15–40 240 (99.17)

N = 242.

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that Korean immigrants with a higher level of hwabyung symptoms are morelikely to show a higher level of depressive symptoms.

Multivariate Analysis

Two separate hierarchical multiple regression (R2) analyses were performedutilizing three blocks to assess factors contributing to either hwabyung ordepressive symptoms. Sense of self-esteem was entered in the first blockfollowed by social support, which was entered in the second block. In thethird block, individual characteristics relevant to the demographic makeup,participants’ relationship with Korea, and acculturation were entered. Thefindings from previous studies consistently demonstrate the statisticallysignificant role of self-esteem and social support in explaining the levelof psychological symptoms (Kim, 2004; Park & Song-Bernstein, 2008; Shinet al., 2007; Wu, Noh, Kaspar, & Schimmele, 2003). By entering sense of self-esteem and social support in the first two blocks, the importance of thesetwo coping resources in explaining hwabyung or depressive symptoms wasassessed separately from the individual characteristics of participants in thepresent study.

In order to perform the data analysis, a number of variables related toindividual characteristics were dichotomized in the following manner:

1. Demographic information: gender (0 = men, 1 = women), live with apartner (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), andusing 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 Englishproficiency of participants and their use of Korean at home. As a morerecent immigrant group, Koreans often prefer to use their native languagewhile interacting with members of their own families and ethnic community(Jeon, 2008, 2012). At the same time, approximately 77% of Korean immi-grants use English as their primary language at work (Kim & Wolpin, 2008).For Korean immigrants, the use of their own native language at home canstrengthen the interaction among family members, while their English profi-ciency may affect their overall functioning in other domains of everyday lifeincluding employment (Jeon, 2010; Zhen, 2013). Because of this reason, it is

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speculated that English proficiency and use of Korean at home have differentpsychological ramifications.

In regard to education, the previous findings demonstrate that Koreanimmigrants who attained higher education in the United States showsignificantly 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 andamong those, slightly more than two-thirds (n = 78; 67.8%) received a grad-uate school diploma. Rather than relying on the level of overall educationalattainment, in the current study, the psychological effect of immigration wasassessed based on the education received in the United States.

The literature on Korean immigrants consistently report the difficultiesinvolved in collecting data relevant to their income (Johnson, 2000; Kwon,2003). To increase participants’ responses in the current study, the annualfamily income was collected by grouping it into several categories. For dataanalysis, the annual family income was reorganized into two categories, overor less than $50,000. According to the U.S. Census Bureau (2004) the medianannual family income of Korean immigrants was $47,624. Thus, an annualincome of $50,000 is an appropriate amount that assesses the economicstanding of Korean immigrant families.

FACTORS CONTRIBUTING TO HWABYUNG 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, socialsupport, and individual characteristics explained 38% of the variance inhwabyung symptoms (F(14, 208) = 223; p < .001). The incremental changefor each of the three blocks was also significant. Five independent variableswere found to be significantly related to hwabyung symptoms. Of thesefactors, 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. Takentogether, a sense of self-esteem, social support, and individual characteristicsexplained 25% of the variance in depressive symptoms (F(14, 207) = 4.90;p < .001). The incremental change for each of the three blocks was alsosignificant. Similar to hwabyung, social support and sense of self-esteem

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TABLE 3 Contributing Factors for the Changes in Hwabyung Symptoms

Hwabyung symptoms

Predictors ß SE Partial correlation

Block 1Sense of self-esteema −.22∗∗∗ .11 −.24

R2 = .16F = 43.39∗∗∗ (1, 221)

Block 2Social supportb −.41∗∗∗ .03 −.43

R2 change =.12F change = 36.79∗∗∗ (1, 220)

Block 3Individual characteristics

Age −.02 .08 −.02Women .13∗ 1.07 .15Living with a partner .01 1.60 .02Owning a home −.04 1.10 −.05

AcculturationThought about re-immigration .09 1.06 .11English proficiency −.03 1.14 −.03Use Korean at home .11 1.26 .13Length of stay −.03 .09 −.02

EducationNo education in the U.S. −.13 1.47 −.10Graduate school education in the U.S. −.24∗∗ 1.52 −.20

IncomeAnnual family income > $50,000 −.05 1.27 −.06Receive money from Korea .16∗∗ 1.91 .19

R2 change = .10F change = 2.73∗∗ (12, 208)

List-wise method for missing data; List-wise method was chosen due to a relatively small amount ofdecrease in sample size available for the data analysisN = 223; ∗p < .05, ∗∗p < .01, ∗∗∗p < .001.Overall F(14, 208) = 9.16; p < .001.aSense of Self-esteem: The Rosenberg Self-Esteem Scale.bSocial Support: The Social Support Scale.

were significantly associated with depressive symptoms, explaining 7.84%and 6.25%, respectively, of the variance in depressive symptoms. Unlikehwabyung, however, no individual characteristics were significantly relatedto depressive symptoms.

DISCUSSION AND PRACTICE IMPLICATIONS

The findings demonstrated relatively lower levels of hwabyung and depres-sive symptoms among the participants in the current study. Also demon-strated was the statistically significant correlation between hwabyung anddepressive symptoms. In addition, the findings highlight the important role

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TABLE 4 Contributing Factors for the Changes in Depressive Symptoms

Depressive symptoms

Predictors ß SE Partial correlation

Block 1Sense of self-esteema −.26∗∗∗ .11 −.25

R2 = 15F = 38.13∗∗∗ (1, 220)

Block 2Social supportb −.28∗∗∗ .03 −.28

R2 change =.05F change = 12.92∗∗∗ (1, 219)

Block 3Individual Characteristics

Demographic informationAge −.11 −1.17 −.08Women .01 .11 .01Living with a partner −.09 −1.32 −.09Owning a home −.03 −.42 −.03

AcculturationThought about re-immigration −.06 −.99 −.07English proficiency .05 .73 .05Use Korean at home .02 .36 .03Length of stay −.07 −.71 −.05

EducationNo education in the US .07 .78 .05Graduate education in the US .01 .12 .01

IncomeAnnual family income > $50,000 −.02 −.25 −.02Receive money from Korea .08 1.25 .09

R2 change = .05F change = 1.24∗∗∗ (12, 207)

List-wise method for missing data; List-wise method was chosen due to a relatively small amount ofdecrease in sample size available for the data analysisN = 222; ∗∗∗p < .001.Overall F (14, 207) = 4.90; p<.001; Total R2 = .249.aSense of Self-esteem: The Rosenberg Self-Esteem Scale.bSocial Support: The Social Support Scale.

of coping resources in explaining the changes in the levels of both hwabyungand depressive symptoms among Korean immigrants. Among the variablesrelated to individual characteristics, education attained in the United States,receiving financial support from Korea, and being women appear to havesignificant impacts on hwabyung symptoms. In contrast, no factors relatedto individual characteristics were found to have significant impacts ondepressive symptoms.

Levels of Hwabyung and Depressive Symptoms

In the current study, the mean score of hwabyung symptoms was 12.01. Thismean score was approximately six points lower than the findings from the

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previous study conducted in Korea, which was 18.38 (Kwon et al., 2008).This outcome may be because of the data collection method. Unlike thecurrent study conducted in a community setting, the previous study wasconducted in a clinical setting (Kwon et al., 2008). All participants werewomen recruited through advertisement or individual contacts. Women oftenshow higher levels of psychiatric disorders in comparison to men (Mumford,Minhas, Akhtar, Akhter, & Mubbashar, 2000). Thus the gender of the par-ticipants as well as the relatively small sample size (n = 53) might haveinfluenced the previous study’s outcome. In regard to the level of depressivesymptoms, the current finding (M = 10. 57) is similar to the national samplein Korea (M = 10.60). Moreover, the level of depressive symptoms foundin the current study is notably lower than the findings of previous studiesconducted on Korean immigrants in the United States, which ranged from12.6 to 17.6.

The relatively lower levels of hwabyung and depressive scores foundin the current study may be connected to the socioeconomic characteristicsof the research participants. Three-quarters (n = 180; 74.4%) of the par-ticipants reported that their family income exceeded $50,000 a year, andapproximately one third (n = 74, 30.6%) of the participants reported thattheir annual family income was more than $100,000. Also, the participants inthis study may have a better sense of life gratification due to the extendedlength of their residence in the United States. The median length of resi-dency among the participants in the current study was 10 years. This meansthat the study participants could readdress their earlier hardships throughimproved economic conditions, language skills, and social interactions withmainstream society (Hurh & Kim, 1990b; Kim, 2009). These positive experi-ences might result in an enhanced sense of psychological well-being amongthe study participants.

In addition, a relatively lower level of hwabyung and depressive symp-toms may stem from sampling issues. Using a non-probability samplingmethod, this study collected the data from social institutions located inthe Korean ethnic community. Since these organizations become a sourceof support for the immigrants who attend these institutions, participantsin the current study might have a strong sense of connectedness to othermembers of their institutions. This sense of connectedness may become asource 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 foundin the current study is higher than those of the general population in theUnited States ranging between 7.94 and 9.25. Despite their relatively advan-tageous circumstances in comparison to other Korean immigrants, difficultiesassociated with the acculturation experience might have increased the levelof their depressive symptoms.

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Correlation Between Hwabyung and Depressive Symptoms

In the current study, the findings suggest that Korean immigrants who sufferfrom higher levels of depressive symptoms may be more likely to experienceincreased levels of hwabyung symptoms. This outcome has an importantclinical implication. Not only can hwabyung be comorbid with depression,but social workers should give careful attention to the ways Koreans expresstheir psychological distress. Korean immigrants tend to underutilize men-tal 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 bewhy, when suffering from hwabyung, Koreans often seek help from physi-cians, traditional medicine, and folk healers rather than psychiatric help (Min,2004b).

Min (2004b, 2008) identifies the differences in symptom characteristicsbetween hwabyung and depression. People with hwabyung frequently com-plained of symptoms that were not part of depressive symptoms. Hwabyungcan manifest itself through respiratory stuffiness, an epigastric discomfort, aheat sensation, subjective anger, and palpitations. In addition, people withhwabyung often express a unique Korean psychology called haan, “a feel-ing of inward frustration that is derived from a sense of resignation, defeat,and nothingness” (Kim, 1999, pp. 126–127). Additionally, people suffer fromhaan because of abuse, exploitation, discrimination, violence, or other formsof social injustice that they have experienced without having resources torectify the wrong. It has to be noted that Koreans believe their experi-ences of oppression and social injustice cause hwabyung (Min, 2004b, 2009).By noting unique symptom expressions, psychosocial stressors, and the tra-ditional remedies for hwabyung, social workers can enhance their clients’compliance with intervention plans, which will result in better therapeuticoutcomes.

In regard to psychiatric intervention of hwabyung, Min (2004b,2009) introduces a number of psychosocial treatment modalities effectivefor hwabyung including short-term based psychotherapy, and cognitive-behavioral therapy. The focus of these psychosocial treatments includessomatic symptom reduction and management of anger. Additionally, thecombined use of antidepressants and antianxiety medicine is recommendedin treating hwabyung symptoms (Min, 2004b, 2009).

The Role of Coping Resources in Lessening Hwabyung andDepressive Symptoms

The findings of the current study demonstrate that social support andself-esteem will strengthen the ability of Korean immigrants to cope withboth hwabyung and depressive symptoms. Indeed, the buffering effects of

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social support and a sense of self-esteem on psychological symptoms wereobserved 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 thesecoping resources have on hwabyung and depressive symptoms. Takentogether, social support and a sense of self-esteem explains 24.25% of vari-ance in hwabyung symptoms. In contrast, these coping resources explainonly 14.09% of the variance in depressive symptoms. These findings sug-gest the important role that coping resources play in explaining hwabyungsymptoms in comparison to depression.

Social workers can foster social support systems of Korean immigrantsand their sense of self-esteem by being familiar with Korean culture. Theirethnic community is where Korean immigrants find social support (Choi,1997; Kim et al., 2005; Noh & Kasper, 2003). For instance, over 70% ofKorean immigrants are affiliated with churches in their ethnic community(Hurh & Kim, 1990b). The Korean church enhances immigrants’ search forthe meanings of their uprooting and re-rooting experiences. The church isan inclusive and accessible social institution regardless of sex, age, or socioe-conomic status. It functions as a “reception center” for new immigrants byproviding needed assistance for their resettlement, including information andcounseling on employment, health care, and children’s education (Kim &Grant, 1997). It also plays a role as an educational center where immi-grants’ children can learn the Korean language, history, and culture. Formany Korean immigrants, their ethnic church becomes an extended familywhere they find a sense of belonging, security, and comfort.

Economic Hardship, Being Women, Education, and HwabyungSymptoms

Economic deprivation appears to be closely related to hwabyung symp-toms. When immigrating to the United States, Korean immigrants oftenexperience a downward economic slide. Their professional experiencesand 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 lan-guage barriers and limited financial means. At times, they may even have torely on financial support from their family members in Korea. Their experi-ence of financial insecurity might manifest as heightened levels of hwabyungsymptoms. Indeed previous findings have shown increased levels of psycho-logical symptoms among Korean immigrants who experienced difficulties inmeeting 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 tohwabyung due to their multiple role obligations as wage earners, moth-ers, 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 atrestaurants, drycleaners, and grocery stores in their ethnic community. Thesewomen become unpaid workers if their families have self-owned businesses.At home, they are expected to maintain traditional role obligations by takingfull responsibility for household tasks and child rearing. They face increasedlevels of marital conflict when they demand a more egalitarian-based conju-gal relationship. As stress accumulates in their daily lives, it can be manifestedas heightened levels of hwabyung symptoms.

Previous findings show that Korean immigrant women develop anincreased level of positive sense of self by recognizing their contributions tothe well-being of the family (Lim, 1997). Creating programs for Korean immi-grant couples to enhance their ability to share family obligations can helpKorean women overcome their struggle with multiple role obligations. Suchprograms can promote emotional closeness and communication skills thatcan reinforce harmonious relationships between Korean immigrant couples.

Having a graduate education in the United States appears to have apositive mental health effect for Korean immigrants. While examining thesociocultural adaptation patterns of Korean immigrants, Hurh and Kim (1984)found a significantly higher level of acculturation among those with under-graduate or graduate degrees attained in the United States. Regardless oftheir length of residency, these Korean immigrants show a higher degreeof social integration. Through their education, these Koreans enhance theirEnglish proficiency and professional credentials, which enable them to findbetter economic opportunities. Indeed, immigrants experience faster earninggrowth as they acquire not only English proficiency but also professionaltraining (Park, 1999). Creating language and professional training programsthat are accessible, affordable, and flexible enough to accommodate theneeds of Korean immigrants can foster their ability to support family mem-bers. Such efforts can contribute to the psychological well-being of Koreanimmigrants and their families.

LIMITATIONS OF THE STUDY AND SUGGESTIONS FOR FUTURESTUDY

The current study has to be considered preliminary and several limitationsshould be acknowledged. This study employed a cross-sectional design.It did not measure the changes in hwabyung or depressive symptoms overtime nor did the data collected through this design allow for assessing causeand effect. The sampling method and geographical specificity of the data

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collection sites are other areas of concern. Because of the conveniencesampling method and relatively small sample size, the generalizability of thefindings is open to question. By employing a more rigorous data collectionmethod, future studies should increase the size and variability of the sam-ple, and consequently the generalizability of the findings. Another concernis social desirability. This study was conducted using a self-administeredsurvey that had an inherent limitation such as the possibility of under orover reporting due to response bias.

In the current study, a statistically significant correlation betweenhwabyung and depressive symptoms was found. However, this finding maynot be sufficient in deciding whether hwabyung and depression are identicalpsychiatric disorders. The previous studies report that hwabyung symptomscan manifest without comorbid symptoms (Min, 2008; Min & Suh, 2010;Min et al., 2009; Park 2004). For instance, based on a study conducted on221 psychiatric patients in Korea, Son (2006) found that 15% of the respon-dents in the study were diagnosed only with hwabyung without havingany other co-occurring psychiatric distresses. In a more recent study, Minand colleagues (2010) found a significant correlation between the symp-tom profile of hwabyung and anger, rather than depression. Further studiesneed to be conducted to determine whether or not hwabyung is a culturallypatterned expression of psychiatric illness arising from major depression.

In addition, a number of studies found a statistically significant linkbetween 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 otherforms of social injustice may cause the onset of their hwabyung symp-toms. However, in the current study, the link between hwabyung and socialinjustice has not been assessed. This requires future investigation.

In the current study, no factors related to individual characteristics weresignificantly associated with depressive symptoms. The differences in demo-graphic characteristics of individual Korean immigrants and their level ofacculturation, educational attainment, and financial circumstances appearnot to predict the changes in depressive symptoms. Although these findingsmight suggest the differences between hwabyung and depressive symptoms,the influence of limited variability among samples and small sample sizemight have contributed to such an outcome. Future studies should employa more rigorous data collection method. Such an effort could yield a clearerunderstanding of the link between the individual characteristics of Koreanimmigrants and their experiences of psychiatric symptoms.

CONCLUSION

The findings of the current study enhance the cross-cultural insights byidentifying not only the relationship between hwabyung and depressive

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symptoms, but also the relative importance of coping resources and individ-ual characteristics on both hwabyung and depressive symptoms. Despite thestatistically significant correlation between hwabyung and depressive symp-toms, the findings also highlight their differences. It appears that copingresources play a much bigger role in explaining the changes in hwabyungsymptoms than depression. The findings of the current study demonstratethat receiving financial assistance from family members or relatives in Korea,or being women can increase the vulnerability of Korean immigrants tohwabyung. On the contrary, those who attained graduate school educa-tion in the United States are less likely to experience heightened levels ofhwabyung symptoms. However, the findings of the current study demon-strate that no individual characteristics explain the changes in the level ofdepressive symptoms.

Social workers must be aware of the importance of culture that shapesnot only individuals’ experiences with psychological symptoms, but also theircoping 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 Koreanimmigrants and their coping behaviors, social workers can provide culturallyappropriate services that address the difficulties involved in their immigrationexperiences, and the ability of Korean immigrants to overcome them.

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