Journal of Cross Cultural Gerontology 11: 229-254, 1996. (~) 1996 Kluwer Academic Publishers. Printed in the Netherlands.

Self-care strategy of elderly Korean immigrants in the Washington DC Metropolitan Area K E U M YOUNG C H U N G PANG College of Nursing, Howard University, Washington, DC, USA

Abstract.The elderly Korean immigrants in the Greater Washington, DC Metropolitan Area use emotional self-care practices to counteract sad and depressive experiences. They tend not to use professional medical help and/or prescription medicine. Their choice of a selfcare mental health strategy is a function of several sociocultural and historical factors: the Korean concept of self, life-long caring role, concepts of a morally exemplary emotional life, religious and cosmological beliefs, beliefs about depression and mental illness, systematic and holistic medical principles, political and social upheavals in Korea. Additional factors include the challenge of transition and immigration to a new culture and country, the USA, with its lack of available resources for the immigrants, such as time with their adult children, lower socioeconomic status, language facility, and transportation. Specific self-prescribed self-care strategies for depression include cognitive strategies, religious strategies, physical strategies, social strategies, and artistic strategies. Key words: Ch'enyom ('giving up'), Depression, Korean immigrants,Mental health, Self-care

Abbreviations:(K)DIS = (Korean) diagnostic interview schedule; SKIGD - semi-structured Korean interview guide for depression

Introduction: Mental health self-care According to our research, there is little evidence that elderly Korean immigrants have received psychiatric care in a community or hospital setting for depression or that they use antidepressants, even though the informants responded that they were depressed when interviewed with the Semi-Structured Interview Guide for Depression (SKIGD) and they were diagnosed as having major depression according to the Korean version (Lee et al. 1986) of Diagnostic Interview Schedule (DIS) (Robins, Helzer, Croughan & Ratcliff 1981). They often said 'What can you do? Life must go on. I continued to work. I had to work. If not, my children would have starved to death.' These immigrants survived and are still surviving. Do they have special tolerance to depression? Have they developed ways to live with depressive experiences? Perhaps they have alternative ways of caring for themselves? Or are they using a combination of all of the above?

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The sense of control over one's well-being has been a major theme in health maintenance and promotion for many years. Engel and Schmale (Engel 1968; Engel 1971; Engel & Schmale 1967; Schmale 1972; Schmale & Engel 1967), for example, suggested that feelings of helplessness and hopelessness that develop in patients in response to situations of loss facilitate the development of existing somatic predisposition or increase vulnerability to external pathogens, resulting in disease. Rodin (1968) agreed, but argued that this mental-physical health relationship was both direct and indirect. Cohen, Tyrrell & Smith (1991) stated that there is the direct disturbance of normal physiological functioning by emotional distress or by suppression of emotional expression or symbolization. That leads to organic damage. For example, depression impairs the immune response and renders the person more vulnerable to infection such as the common cold. Rodin (1968: 1274) pointed out that although a sense of control may have a direct effect on health status, it is also possible that people who have a high level of perceived control have better health because they try to prevent or remedy their own health problems. Health might be improved by the gathering of health-related information, engaging in self-care, actively interacting with medical providers, and/or adhering to medical regimens. A self-prescribed self-care mental health strategy is rooted in this 'control over one's well-being'. It includes those activities that individuals personally initiate and perform on their own behalf in maintaining life, health, and wellbeing (Orem 1971:13). It is those techniques of mental health self-care that are thought to increase people's sense of control over their well-being and thus directly and indirectly influence their mental and physical health. A self-prescribed self-care approach to mental health is also one that is heavily influenced by the individual's perceptions of mental health and illness. The self-assessment and resulting health-seeking behavior will be shaped by the beliefs, habits, and practices of the group to which the individual belongs. Individuals will choose and follow courses of action they judge to be beneficial to their own functioning which are consistent with their social values and rules. There is also the opinion that all Koreans make diagnosis and offer advice or treatment regimens to people whom they know are ill. This produced the phenomenon that the capability of professional physicians has been discredited (Rhi 1983). However, despite its significance, there is relatively little in the literature concerning the use of mental health self-care strategies. Koenig & Meador (1996) found that respondents infrequently turned to health professionals in their attempts to cope with emotional stresses. Folkman, Lazarus, Scott &

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Novacek (1987) recently demonstrated that older persons tend to use more passive, emotion-focused coping behaviors than do younger individuals. In terms of specific mental health self-care strategies, Koenig, George & Siegler (1988) found that accepting situations was a coping mechanism for older adults. Having done the best they could to solve a problem, they accepted it and continued on with their life. They adopted the underlying philosophy of the popular 'Serenity Prayer: God grant me the serenity to accept things I cannot change, the courage to change those things I can, and the wisdom to know the difference'. Murphy (1982) studied the relationship between depression in the elderly and a social support self-help strategy. She concluded that the majority of older persons who are suffering from social problems, adverse life events, and poor health remain remarkably cheerful; and it is only those who lack a confiding relationship who appear to be vulnerable to depression in the face of these problems. Realizing that confidants can function as buffers, she proposed that the capacity for intimacy is an essential protective quality against mental illness, emphasizing that the capacity for intimacy was an attribute not of the confidant but of the individual's own personality. The research literature is even sparser in accounts of various social/cultural groups and the 'value prisms' through which they form their mental health/illness conceptualizations. This is especially true for large numbers of elderly Korean immigrants, who have successfully employed mental health self-care strategies to counter depression. Cheung (1987) studied mental health problem conceptualizations of Chinese psychiatric patients in relation to their pattern of help-seeking and ways of coping. She found that patients who conceptualized their initial problems in purely psychological terms were more likely to use self-directed psychological coping methods and therefore to delay initial professional consultation. This paper, which is part of a larger research initiative, will address some of these gaps in the literature. It will explore the patterns of mental health self-care used by elderly Korean immigrants in the USA to prevent and relieve sadness and depression. Specifically, it will first examine the influence of several Korean sociocultural factors in choosing a self-care strategy. The paper will then describe particular self-care strategies used by this study's elderly Korean immigrants. The lessons learned from this research should be particularly important in the mental health treatment of both elderly Americans and elderly immigrants, which are populations that face the additional stressors of deteriorating health, the death of their spouse and peers, and changes in financial and social status.

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Factors encouraging self-care strategies The choice of a self-care strategy for mental health problems is the function of several sociocultural influences, including the Korean concept of self, concepts of a morally exemplary emotional life, religious and cosmological beliefs, beliefs and traditional medical theory about depression and mental illness, political, international and social upheavals in Korea, and the challenges of transition and immigration to a new culture and country, the USA.

Concept of self The concept of self can vary across cultures (Marsella 1980: 269). In contrast to the concept of the individual self in Western culture, the Korean self-concept is related to the ego's various interpersonal and group relationships, including those with family, friends, and the society at large. Furthermore, the Korean self-concept includes ancestors, nature, and the cosmos, in both its natural and supernatural aspects. Baik (1979: 283-286) termed the self-concept of Koreans the 'all-inclusive self'. This orientation tends to foster obedience and self-sacrifice for group goals and group harmony. Because of this strong group orientation, Koreans may feel a sense of belonging and protection even if no tangible support is forthcoming. Individual-centered, self-fulfilling actions may not be appropriate in this context.

Concept of a morally exemplary emotional life. Asians tend to regulate or 'digest internally' emotions instead of venting and expressing them publicly. Asian cultures emphasize harmony for people and environment instead of antagonism or mastery. In order to preserve harmony with people, they often use indirect communication. Silence is sometimes used to communicate disagreement non-verbally. Confrontation may be viewed as aggressive, bringing conflict and making the situation worse by disturbing harmony (Chin 1993). In Asian cultures, implicit meaning is stressed and often considered more significant than verbal communication. Metaphor, symbolism and non-verbal nuances are substituted for direct verbal communication (Chin 1993). Asian cultures emphasize mutual interdependence as a symbol of maturity, through caring for one another in the extended family. The emphasis is on family and community rather than on the individual. Something that brings shame to an individual is experienced and shared by an entire family or community. Modesty is an important value among Asians. It enables people to remain modest while obtaining recognition from others. Westerners who do not understand this phenomenon often view it as showing poor self-esteem (Chin 1993). The expression of emotions involves an understanding of moral rules (Armon-Jones 1986). For Koreans, emotional self-reliance is favored by the Confucian principles of morally correct emotional expression, which dis-

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courage the verbalization of opinions to one's superiors. Confucius said that patience is the greatest of all behaviors, and if everyone is patient, all will be in perfect harmony. Furthermore, if one hears unpleasant things, one should pretend he has not heard them (Kim 1972: 26-17). In Buddhist thought as well, verbalization is discouraged because it is considered an obstacle to 'awakening' (Balk 1979). This tradition is still carried on in that family members are discouraged from conversing at meal time. Talking too much is not considered a virtue. Being able to understand one another by being sensitive to others' wishes without talking is even more highly appraised than skillful communication. Filial piety, respecting seniority, courtesy, etiquette, and demeanor as a form of mental and behavioral discipline by self-cultivation are considered very important in order to keep peace with self as well as with others. Koreans believe that the mind and emotions are strengthened by internal actions. A variety of Korean sayings highlight the belief that mental concentration is the greatest of achievements: body and mind are one; the mental state for appreciating happiness is to lose oneself; one should lose oneself and contribute to the whole system; if one can discipline the self he can govern the whole world; if one's emotions and soul are disciplined and concentrated, everything will be possible; if one earnestly and eagerly wishes for something, heaven will move and help. Elderly Korean people may endure suffering inside themselves to create harmonious interpersonal relations. They commonly consider servitude to others their duty and virtue. Older Koreans are very much concerned about interpersonal relationships and are very careful in interacting with people, perhaps because they believe that mutual support creates a meaningful life. They tend to think and operate in terms of 'shoulds' and 'oughts'. Although they rarely express their likes or dislikes, they expect others to know their preferences and carry them out, a psychological characteristic known as yi shim jun shim (Rhi 1974). When they or others deviate from moral standards or expectations, elderly Koreans may feel sad, disappointed, or depressed, but try not to express these emotions. They do not readily let others know their grudges or complaints because they believe it is best to maintain peace or at least to continue the status quo. Yielding and sacrificing for others, rather than self-actualization and self-realization, are considered primary virtues (Baik 1979). ,~

Cosmology and religion. The rules of nature and harmony with nature are worshipped and respected. Koreans believe that nature and human beings can live in holistic harmony. Because the self is considered part of nature, natural healing is part of self-care. This can include meditation in natural settings and

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appreciation of nature by spending time quietly in the mountains or by the sea. Elderly people, whether healthy or ill, turn to nature to refresh the body and mind and to enhance inner peace. Confucians believe that health and illness are up to divine fate. According to Taoism, men who conduct their lives in accordance with the doctrine of Tao accumulate essence and their spirit realizes its full potential and preserves harmony (Unschuld 1985: 125). Baik (1979) reported that Koreans can mobilize multiple religious traditions to defend themselves. Ancestors' wishes should be obeyed so that their blessings will ensure one's good health. Shamanism influences Koreans to seek assistance from supernatural powers when they face problems they cannot solve by themselves. Deuchler (1983) and Hsu (1972: 83) have reported that performing healing rituals is the shaman's most valued function. Buddhism encourages Koreans to live mercifully and to try to prevent unfortunate conditions, including poor health. When one is faced with adversities, Buddhism encourages one to attribute them to what one did wrong in a past life and accept the situation as fate. Awareness of facts in human life and nature are important. Removing distress by emptying a chaotic mind and self-resignation are encouraged. Some Koreans are also influenced by Christianity and may have guilt feelings that encourage self-care. The Tao Te Ching discusses mental health self-care, in terms of a selfrenewal process: 'They can renew themselves before being worn out' (Chen 1989: 91). Chen interprets this renewal process as follows: The retreat or quieting down from life's activities leads to psychic clarification. The retreat is a self-emptying process that prepares the self for spiritual renewal. Thus, empty space, necessary for physical motion, is also necessary for spiritual regeneration, while a full state leaves no room for change or renewal. Worn out, thus renewed. This retreat and withdrawal not only prepares the individuals for return to the world of activity, it is also necessary to maintain harmony among beings. Without this retreat or self-emptying there would be more conflicts and wars in the realm of the many. The rhythm of retreat and clarification readjusts the balance and brings about harmony in the word. (1989: 33) The Taoism and Confucianism are an important cultural inheritance which has had a great influence on the Korean personality (Kim & Rhi 1976). The Taoist concept of self-renewal aims at developing a self that perceives the inner and outer world realistically and tries to liberate itself from all forms of emotional bondage. There are strong psychotherapeutic elements in Tao that include processes and methods for developing insight into one's mind. Tao alleviates the existential anxiety of the average person as well as pathological

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anxiety (Kim & Rhi 1976). Taoist principles state that the self can direct himself, herself or others toward therapeutic efficacy. Rhi (1970) sees the Tao as an affirmation of humanism, because it is concerned not only with pathological situations but recognizes and pursues the infinite potentiality inherent in the normal human mind. The humanistic orientation in traditional culture has helped develop the understanding by emotionally opening up the characteristics of the Korean personality (Kim & Rhi 1976). Tao allows psychotherapy that understands and treats pathology, and also helps people discover and cultivate their healthy potential. Cultivating the basic attitudes of mind and the seven emotions (heart) is regarded as a fundamental moral imperative. In Confucian thought, only selfcultivation and discipline enable one to gain full control of one's destiny and to attain sagehood. Confucianism asserts that human beings have the ultimate goal, not only to work for individual control of negative feelings such as hate and greed, but also to dedicate themselves to the larger common self of humanity. Emphasis is placed on the importance of interpersonal relationships to overcome family conflicts in order to ultimately serve the whole of humanity (Kim 1994). Yi Toegye (1501-1570), a highly respected Korean orthodox neo-Confucian philosopher, advised people to control and sublimate such emotions as anger and greed (Kim 1994). He provided instructions in his book Ten Diagrams of Sage Learning. Yi's work has been widely acclaimed in Korea, China, Japan, Europe, Russia, and elsewhere. He emphasized strict adherence to rituals to foster self-discipline. He also taught that the Taoistic concept ofWu Wei (nondoing and awareness of it) as a means to self-mastery. Yi's major observation was that nature seems to be still (non-doing) but is actually in constant motion and creation. The phenomena of nature unfold easily, without much effort. Yi observed that nature (Heaven) is devoid of anxiety, greed, or eagerness to accomplish anything. Likewise, a person in harmony with his inner nature may be as busy as external nature and yet still enjoy inner calm. In this way, the sage achieves perfect freedom from anxiety and distress (Quoted from Kim 1994). Korea is a multi-religious country where 80% of the population has some affiliation to Christianity, Buddhism, Confucianism, Taoism, shamanism and other new and quasi-religions (Kim et al. 1993). One of Buddha's fundamental insights is the recognition that everybody suffers from illness, growing old, death, separation from loved ones and unfulfilled desires. It is possible to end this pain by the use of 'the Eightfold Way - correct views, correct intentions, correct speech, correct behaviors, correct living, correct effort, correct attitude, and correct concentration' (Unschuld 1985:135). Accordin~

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to Buddha, every action is evil and it harms others, one self, or harms both others and oneself (Unschuld 1985: 135). In Korea the emphasis in Confucianism was on emotional control for the sake of cultivating an attitude of reason in hierarchical interpersonal relationship especially toward elders (Rhi 1986). Although all the Asian religions have holistic spiritual aspects, each religion seems to have an emphasis which ultimately influence mental health and maturity: correct behaviors in Confucianism, insight (cognitive) in Buddhism, being natural (non-doing) and cosmological (physical) in Taoism.

Beliefs about depression. Depression is a disorder of perception and interpretation. Because culture shapes perception and interpretation and defines what kinds of interpretations are abnormal, the origin and expression of depression have cultural variations (Good, Good & Moradi 1985; Kleinman 1986). In Korea, mental illness is stigmatized, and participating in psychotherapy with mental health professionals is associated with shame. Additionally this treatment modality is not well known to most Koreans. Baik (1979) pointed out that it is difficult for Koreans to establish a therapeutic relationship with health professionals because they tend to depend on themselves for emotional self-care in most instances, except for seeking occasional help from supernatural powers. Elderly Korean immigrants may also avoid professional care because they do not feel they deserve it or do not know how or where to get such services. Maum can be translated into English as mental aspect, nerves, thought, emotion, soul and spirit. Some Koreans believe that distress related to maum need not be treated by a doctor because a person's soul belongs to the person and it should be self-treated. One's nervous or psychic aspect can be interfered with by psychosocial factors, such as one's financial misfortunes, that are believed to be subject to correction by the person. In Korea, individuals can address psychic troubles by drawing on numerous kinds of interventions, including modem biomedicine, traditional Korean medicine (herbal remedies, acupuncture), natural cures, and popular medicine related to Buddhism, Christianity, and shamanism (Rhi 1974:139). Political, social and international upheavals in 20th-century Korea. The elderly Korean informants now living in the USA are the survivors of a generation that went through the pre-Wodd War II Japanese occupation, World War 11, the Korean War, riots, and its tragic aftermath. Most have lost family and friends, and many have been uprooted severe times, so they have had far more exposure than the average world citizen to the sorts of events that can lead to depressive syndrome. Koreans who dived through this period of phys-

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ical hardships and economic scarcity had to be self-reliant and self-sufficient to survive. Osgood (1962 331) stated that the Korean personality has been toughened by these experiences and is 'capable of the sustained quiescence of the hibernating bear and the fury of the goaded tiger'. Yun (1976) stated that endurance has been an essential psychological quality for the survival of the individual and the nation, as has moderation that fosters a restrained, sparing, and temperate state of mind.

Immigration-induced changes. In the USA, few elderly Korean immigrants share their current problems with their adult children, whom they see as busy and struggling to succeed while facing the conflicts and frustrations of immigrant life. In particular, they expressed concern about being a burden to their children. They strive to be independent from their children's support as much as possible. On the other hand, some elderly immigrants may expect emotional and financial support from their children and become depressed if it is not forthcoming. Language and transportation difficulties are additional problems.

Study sample and methods According to 1990 census data, there are 798,849 Korean residents in the USA, an increase of 125% since the 1980 census. Approximately 33% reside in California, 12% in New York, and 5% in Illinois (US Bureau of Census 1990). This study was conducted in the Greater Washington DC Metropolitan Area, which has a growing population of about 70,000 Koreans (Borgman 1994: A 10). The sampling pool was defined as all elderly Korean immigrants in the area who are 60 years old and over, not in long-term institutions, who immigrated to the USA after 1970. A pool of 995 possible elderly Korean immigrant informants was compiled from various lists of individual contacts, family contacts, Korean church members, Korean elderly associations, and the telephone directory of the Korean Greater Washington DC Metropolitan Area, a directory updated annually by Korean community organizations. After validating the sample pool, a sample of 230 subjects was then selected, using an iterative process of selecting every fifth person. These 230 subjects, in turn, introduced interviewers to other potential subjects from their networks, adding 444 more, for a total of 674 informants. Two sub-samples were then drawn: a sample of 35 informants (the 'cases') who were diagnosed with major depression, and a sample of 35 control informants (the 'non-cases') who had no diagnoses of depression, according to the Korean version of the National Institute of Mental Health's Diagnostic

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Interview Schedule (DIS) (Lee et al. 1986). Further data on these 70 informants' conceptualizations of depression and its symptoms were then gathered using the Semi-Structured Korean Interview Guide for Depression (SKIGD), constructed by Pang (1995). SKIGD includes qualitative questions about patterns of affects recognized by Koreans as signs and symptoms of depressive experiences, causes of depression, patterns of coping, and methods of caring for depressive conditions in terms of Kleinman's (1980) explanatory model. SKIGD also employs the psychological tool of five culturally sensitive thematic stories that probe themes of depression based on DIS-III (Robins et al. 1981) criteria, somatization disorder, and the three Korean concepts of Hwabyung, Han, and Shinggoungshayak (neurasthenia). Using this database, this paper now explores the elderly Korean immigrant population's choice of a mental health self-care strategy, and some of the specific self-care patterns of coping.

Results Eldedy Korean immigrants in the USA seem to understand depression as a psychosocial condition rather than a biological condition, and many do not believe that medication could alleviate depression. They believe that one is responsible for one's own happiness or unhappiness. Depression is not seen as an illness, but rather as a transitory cognitive state that can be overcome through personal determination. Informants report that symptoms of depression include abnormal or senseless behaviors, anger, anxious or fatalistic feelings, body aches, fast heartbeat, loss of sight, disorientation, thoughts of death, and inability to interact with others. However, informants believe that one can avoid depression by being religious, generous, flexible, enthusiastic, and by keeping busy, talking with friends using wit and humor, doing exercises, and relaxing in natural settings (Pang 1994). Although Kim (1991) stated that Koreans tend to blame others and to project onto supernatural beings, the elderly informants in this study tend to blame themselves for lack of harmony with others. Elderly Koreans who have had to endure enormous hardships and distress and have not been able to cultivate the self may have inner conflicts that may lead to depression or somatization or to Korean folk illnesses such as han ('unhappiness or grudges'). Han appears to be the counterpart to guilt in Western culture but includes other aspects such as self-pity and sadness associated with passive frustrations and hostility that result from disappointments in life and unfulfilled dreams and

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Table 1. Comparison in frequencies of types of help mentioned by elderly Korean immigrants

Case Non-case Total

Self

Religion

Family

Other

Total

79 62 141

32 52 84

46 23 69

58 41 99

215 178 393

aspirations. Han is understood to be caused by significant others and self who axe oppressive, disloyal, unfaithful, or negligent. Some elderly Korean immigrants observe with some irony that they are expected to follow their adult children's directions in everyday life, a situation analogous to the si jip sari handa, the subservient role of the new bride in the extended Confucian family. Often, adult children who work outside the home expect their elderly relatives to baby-sit, cook, and keep house. A few informants complained that they had done their share of this kind of work as young brides, why did they have to do it again? These and other interpersonal experiences with adult children may result in painful feelings of betrayal, but elderly Korean immigrants may not consider discussion and negotiation of intrafamily relations to be appropriate. Responses in the SKIGD stories relating to help were coded and tallied. Responses were divided by source of help into self-help, religious help, family help, and help from others outside the family. The frequencies are reported in Table 1. The number of self-help responses was the highest both for the depressives (cases) and the non-case controls. Beyond that, the controls used, in order, religious, others, and help from their families. The cases depend on others, then their families, and they put the least reliance on religion. In other words, everyone depends on themselves, but depressives depend next most on their families, while the controls depend on family the least. Overall, the cases mention help more often (215 times) than do non-cases (178 times).

Five c a s e s t u d i e s

Responses by five informants, three cases and two non-cases, were chosen to examine self-care phenomena qualitatively in depth, with quotes extracted from the tapes of their responses. First is a 62-year-old widower with middle school education, who has lived in a senior citizen's apartment in the USA for three years. He claims that he was not very distressed at his wife's death. He has current major depression, stroke, heart trouble and arthritis. He described a person whom he knows,

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whom he depicted as a severely lonely and depressed man, but the author thinks that he was talking about himself because he was diagnosed as having major depression by KDIS and his psychosocial and physical conditions have deteriorated drastically. He is probably trying in this way to protect his dignity. He said he was enjoying life in America but that his 'friend' was not. He has three daughters and several friends. He worked actively in Korea but he has become unable to work and is bound at home. He helps himself not to be depressed and to enjoy life by thinking of pleasant things: I go to church often not to be Christian but to meet my children and friends. You can get rid of stress in the church at least for the day and have hope for life from sermons by priests. The traditional medicine doesn't work. The cure is to make them happy but who would do that? There is no facility for that. You can't cure depression with drugs. I think it would help if we had some facilities to assist us. When you get stress you get ill. That's why the Korean Association should hold many parties to get rid of the stress. Say what you think. It's not medicine but to make things pleasant. Drugs don't work. They would make your mind unclear. To go anywhere you want is the best medicine. Then you get better right away. Therefore if you learn how to drive and go to places you will be cleared of all illnesses. You will be happy. He actually analyzed the circumstances of elderly Korean immigrant life in the context of independent elders v e r s u s dependent elders in America, relative to depression and loneliness: In America the way of life is different. Young people can't make a living without working. You get depressed when you expect your children to support you and do filial duties, and that is not possible even though they want to. Then you get older and move into government-subsidized housing with welfare and move later on to a nursing home. If you don't understand and adapt to this process, you are going to blame your children. But you can't blame them because they have to work hard, I think. For stubborn Koreans it is hard to accept and adapt to the system of this society. People thought their children would support them and they immigrated to wonderful America but their children are too busy to give a ride when they want to go shopping. Thus the oldest man should be able to drive. Even though they don't work they really need cars to do something and to go somewhere. I know a 77-year-old man. He learned how to drive and now he drives around with his wife and says there is no better country to live in. He can go anywhere he wants and receive his SSI every month. He says that no children would take care of them like that. He is happy to be able to live in a paradise in his later years. He did not even drive in

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Korea. He learned it here. He got over his children's objection by saying that to be able to drive is necessary to him. Now he drives to go shopping or anywhere with his wife. Anyway, he says America is a paradise. Those who can't do that can't live due to loneliness. Second, a 68-year-old widow with an elementary school education, lived with her daughter for a year after her arrival in the USA. She next lived in with a family as a housekeeper and then moved to a senior apartment where she has been living alone for ten years. Her daughter lives far away. Major depression related to bereavement was indicated by KDIS. A tough one is life. I go crazy for not falling asleep until 3 or 4 in the mornings. I make my living since I couldn't die. I miss human friendship the most. I learned to drink and smoke when I was over 40. But I am careful since I have high blood pressure. I like very much to play. I recall my past as I get old. I start to wonder if I am lonely because I committed too many sins in a previous existence? Nobody knows my mind. Nothing I can see and nothing I can hear. Extreme sadness causes no tears. If I lost my mind I would die but my mind stays with me. The worst pity is the men and women who live alone. A widow knows what a widow is about. My father passed away when I was three. My mother passed away when I was twelve. I married at seventeen and lived with my husband for about ten years. I lived most of my life without father because my father passed away when I was a baby. Also, my husband had no father. Loss of significant others left her with a sense of meaninglessness and caused much difficulty. She was still seeking meaning and resolution for her extremely hard and unfair past life. This phenomenon could be called 'Han' among Korean adults. When she was asked, 'Is the sad and depressed condition a mood, a symptom, an illness or a disease?', she said, 'It was not an illness. It was a feeling. It just came from my mind. Just because I was lonely and sad .... I don't know. It was not even an illness. I would call it a nerve illness. It was not an illness because I could soothe and comfort my mind.' It should be noted that she did not label her condition as depression although she expressed extreme emotional distress. She conceptualized the depressive state as normal, although KDIS indicated that she was experiencing depression due to bereavement. I walk outside. I drink liquor .... I feel like dying. I cannot forget. I would forget if I die .... I only go crazy within myself.

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Forgetting is one way of coping, but in her case the trauma is too great to forget so she uses liquor as a maladaptive coping device combined with activities such as walking for recreation. Who could give me help? I soothe my mind - I try to care this way and that and simply wander around like a crazy person. I go out to get some fresh air. I dance, smoke, drink, and play games. I comfort myself by saying that I had too much guilt from my previous existence. It seemed to put her at ease that she thinks she deserves punishment for doing something wrong in a past life. This belief derives from Buddhism and shamanism in Korea, but nowadays Christian informants may show the same pattern. At first, I didn't consider remarriage because I wanted to raise and educate my two daughters, but now I regret it. I had very hard times when I came to America - my son-in-law even meddled with what I ate. I thought that America is also a place where people live and that I could survive anywhere. I walked out of the house. I had all different kinds of hardships, wandering around this and that house. I went crazy when I couldn't sleep at nights. I would intend to sleep again after I visited the bathroom in the middle of the night and go to bathroom with my eyes closed, but once I became awake I couldn't sleep again. That made me crazy. Who else could notice if I die all alone? Could my daughter know? Only ghosts know. I wish I would die just the way I am. Third is a depressed 74-year-old grade-school-educated Christian living in the USA for fifteen years. Her daughter invited her. She blames her depression on her personality: At the worst times, it is to the extent that I would like to kill myself. More so because my personality is not cool and easy. I feel lonely very much. My family lives away from me and my body hurts, my leg hurts, many parts hurt. Since my body is always uncomfortable, I feel lonely a lot. What is different from Korea is that in America I cannot go out, speak, and see even though I have legs, mouth and eyes. To earn money to make living. To live with my four-year-old daughter after taking refuge from North Korea I was sick and tired. My husband died in his thirties (of a disease) .... Many times and still now. It was hard to live alone after my husband died when I was 30 years old. No relatives except my daughter live either in Korea or in America, so all the time I am lonely and depressed. I thought about killing myself. I would like to die without pain. Anyway I have lived my life so that the thought comes to me that I could leave this world as soon as possible.

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When it comes to self-care, she wants to talk to as many people as possible with an open mind, to solve and forget problems. She goes to a quiet place and takes it easy and she feels better. She allows herself to interact with her friends: There are many friends who are nice to me. They invite me places and say comforting words and share food. I appreciate it but I am anxious about being a burden and how I can pay back. She said that her loneliness had become worse because of separation from her daughter and her physical illnesses and maladaptive conditions of immigration. Her self-care areas are cognitively putting up with it, lying down, and going out to get fresh air when feeling restless in her room. Also, she receives moxabustion and acupuncture. Fourth, a non-case, is a 81-year-old, married, college-educated Christian man with three daughters and two sons. He has diabetes. He said about his depressive experiences: It's the individualism. Traditionally, Koreans support their parents and raise their children. It is completely different here. Each lives on his own. In Korea when parents get old, their children support them. Family systems are different. In Korea parents raise their children and want the best for them and want them to distinguish themselves, which is their joy .... When my parents died, it was like the heaven tumbling down and I was beside myself. The father is the heaven and the mother is the earth. The world was coming down on me. I was beside myself. One of my children invited me, lying that America was a paradise. A father is useless here and a mother is used as a kitchen maid. Because we care of my grandchildren we would not be let go. Men go back (to Korea) since they have friends, but this is not the case for women. It is beyond describing. First of all I can't speak English, so I can't go any place. I just stay at home. Aged people are of no use here. There is no work and no fun. You have to keep active to prevent illness. If you are not active, you become ill. He described his depressive experiences in relation to the effects on the family of an individualistic value system, parent's death, hardship during the Japanese occupation and the Korean War, having no meaningful activities, and chronic illness. His self-care is a cognitive approach: You have to get rid of it since it comes from your mind. You have to be determined not to have it. You have to control your mind. It's of no use. You have to think about your everyday life. You can't be sad and depressed day and night just because you feel that way. You have to remove it on

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your own. You have to have mental training. You have to remove and forget about sad things. I would have more affection for my family. I don't know anything else. You have to accept the facts and get over it. If you are in control of your mind then you live, otherwise you are going to die. You have to remove what causes Hwabyung and enjoy your life. You have to try to enjoy your life. Fifth, a non-case, is a 74-year-old female with Catholic faith and no formal education. She has been living with her son, daughter-in-law, and grandchildren in the USA for eight years. She said her family's financial situation is rather poor. She has three children in Korea, but has lost a son. At first I thought about him all the time day and night, and while eating. Yes. Once in a while. More so on certain days. When it is severe I pray to the statue of Saint Mary to forget about it .... But here in America I have been trying to forget it and think about him on holidays. She was able to regulate and control her thoughts about her son as time went by. It may be considered an adaptive strategy for her stress. I pray before Saint Mary, lie down to be easy, and take a walk for a fresh air. I feel relieved to have openly talked. It seems that I would feel better if I either talked or fought with somebody. It is likely that I hide my feeling inside. Sometimes my son tells me to beat up his wife rather than to do nothing when I get mad. Then I say to him that who would beat up their daughter-in-law these days? Laughter .... Here you go to a doctor for drugs. In Korea, drugs are expensive enough. Normally, if she were in Korea, she might not go to health providers but would help herself or do some kind of home or herbal remedy. In general, all of these informants have ways of coping with depression, but it appears that some (the non-cases) are better at doing it. At times the non-cases show a keen cross-cultural perspective on the source of their problems which clearly helps them to cope.

Self-care strategies. When informants were asked: 'What kind of care and treatment do you think you should receive for sadness and depressive experiences?' and 'What are the preventive measures for sadness and depressive experiences?' most of their responses were nature-aided self-help activities with mental, emotional, physical, religious, spiritual, ethical, moral, and social overtones. The degree of self-help is almost surprising, given that they have been used to extended family living. They seem to be aware of when to act collectively and when to act individually in developing self-integrity or

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facing death. Only a few responses mentioned taking medications such as tranquilizers. Their means of self-help are holistic, using nature-oriented, religious, spiritual, emotional, cathartic, physical, and social means to achieve harmony within the self and with self, others and supernatural beings. Although not all informants mentioned nor practiced all of the self-help ways stated below, all wanted to have a calm state of mind, harmonious relationships particularly with family members, respect from others, to be helpful to others and self, and to feel and look happy. Their primary self-help strategies are cognitive, cosmological, religious, physical, and social. Cognitive strategies include keeping one's spirit happy, having a positive attitude, turning one's mind to other things, encouraging and comforting oneself, willing oneself to forget sad and depressing events, and recalling pleasant experiences. One is encouraged to develop a generous and open mind and to avoid selfishness and narrow-mindedness. Koreans are known to face hardships with creative achievements and to find a source of enjoyment in life's cruelties by addressing them through caricature, satire, humor, and wit (Kim 1976; Lee 1988: 179). One informant said: I try to be happy even when I'm in a bad mood or depressed.., keep myself with easy attitude .... I try to live cheerfully .... I try very hard not to feel sad .... I go away by myself and laugh away my depression ... just have to keep my mind at ease .... I have overcome many agonies of sadness .... Keep one's mind open then there is no sadness, depression, Hwabyung, or anything. Koreans believe that experiencing any extreme emotion can injure one's vital energy, and that too much thinking injures one's soul. Because illness develops when one's vital energy is weak, one should allow oneself to be only moderately happy or sad (Kim 1972:12). The sense of self among Korean elderly immigrants serves to restore balance in the body or family system by regulating or governing their thoughts and emotions, to maintain and promote physical health. Some sample responses: Think of positive things; Make up own mind; I pulled myself together thinking that I should not be the way I had been; Reminisce in tranquillity; Know yourself; Comfort self by saying that I had too much guilt from my previous existence; Think positively; Comfort self by thinking of people in worse condition than mine; In tears for a while, snap out of it and pull myself up; Forget depressive experiences one way or another; Understand the nature of depressive experience by yourself; Open-minded; Sooth myself; Make mind comfortable; Keep your mind wide open; Have

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good personality; Bear with it (Put up with it, endure all your troubles); Keep mind comfortable and easy and happy; and Time will heal. Religious strategies include praying and talking with students of Buddhism. Ch'enyom ('giving up') is an indigenous religiously oriented self-care strategy used to orient oneself in the subtle dynamics of interpersonal relationships. Ch'enyom is an ancient translation of chongsa, or 'right thinking', the second component of the Buddhist Eightfold Path. The word derives from the term ch'e, which designates truth, self-awareness, and clarification in the Buddhist tradition. Ch'enyom involves resigning oneself or yielding, rather than abandoning hope. The person who practices ch'enyom relinquishes his needs, wishes, and expectations of others and accepts his palja, or destiny, as being in harmony with the cosmos. In the context of Korean culture, a consciously chosen strategy of 'giving up' in a crisis or situation of interpersonal conflict can increase the person's sense of control. Rhi (1974) pointed out that the Buddhist approach of ch'enyom provides an alternative when the Confucian requirements for family interactions become too burdensome. By doing ch'enyom, an individual gains respect and support and can avoid interpersonal difficulties with family members and significant others if these others share the same value system. Informants repeatedly mentioned that both attending church and praying uplifted their spirits. Koreans and Korean churches have made a more visible religious presence in the USA than any other recent group of immigrants. But as many Koreans know, the Korean churches act just as much as community centers as religious centers. So to some, if not many, their statements about using faith and religion to deal with depression are not always exactly related to religion by itself, but to the strong social development and interaction of friends that are always present at a church. In this sense, some of the religious coping strategies also function as social strategies. Some sample responses: I don't get lonely when I go to church; One can never be lonely when hearing those good words on Sundays; I have no magic formula for a better life but I do hang on to the Bible; When you have faith, loneliness disappears; I pray to God and recite a psalm; I got cured after receiving healing hand at a church, if it weren't for my faith I wouldn't be able to bear the troubles from my husband and my son; You can be healed by the love of God; I ask God for His mercy; People should be treated with devout religious life; Lean on God; Meditate as reading Bible; Pray with all one's heart; Sing hymns; Be and meditate on serenity in nature; Openminded; Sooth myself; Make mind comfortable; Keep your mind wide open; Have good personality; Bear with it (Put up with it, endure all your troubles); Keep mind comfortable and easy and happy.

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Physical strategies for addressing depressive experiences include drinking cold water when one is in a distressed emotional state, deep breathing, obtaining acupuncture, taking remedies such as chungsimhwan to calm the mind, and eating lightly. Activities believed to alleviate depressive experiences include walking alone, spending some time alone, visiting quiet places, doing traditional exercises such as Tae Kwon Do, learning how to drive, participating in recreational activities, listening to music, dressing up, and traveling. Some mentioned that just by keeping oneself busy working, one cannot possibly have time for depression. Some sample responses: I cry sometimes but I make myself busy by working; I soothe myself by doing the household chores; One needs to stay busy and not have any idle free time; Live positively and happily; Develop hobby; I go out to get fresh air, dance, smoke, drink and play games; Lie down and listen to radio; Listen to music, keep myself busy; Go shopping; Walk off depression; Take a brisk walk; Work hard; Work on by myself; Do housework; Buy what I like; Go somewhere you want; Have good food and make yourself feel good; Sleep well and recover strength. In old age, some informants and their children consider physical and mental alterations are considered signs of aging. This fact seems to encourage selfcare for palliative care sometimes. The informants do not expect much positive change in support from others, including from their own children. They believe that they have to change themselves and care for themselves as much as they can, in order to adjust to the new situations and to create harmonious relationships with themselves and significant others. They used to be leaders in a collective extended-familyoriented Korean society, and now they are followers of their children in an individualistic nuclear-family-oriented American society. Confiding is also one example. Even with all their networks of friends in churches and elderly clubs, many Korean elders would have been happier with the close family ties their culture left behind in Korea. Some sample responses: Talk with friends; Talk with relatives; Talking oneon-one with a peer. There is a saying about illness in Korea: 'You should brag about illness'. Another reason why self-care is done is that the majority of the informants are women and they are used to give care to others as mother, grandmother, wife or neighbor. This may help them to care of themselves.

Discussion and conclusions

There seem to be some explanations for Korean elders' use of self-care. They had to be self-reliant and self-sufficient. Historically there have been

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numerous foreign invasions and economic upheavals. The informants - the majority of them are women - have been care providers in their family and community. Besides the self-care, Korean informants are familiar with facts of life and have realistic expectations of life, not idealistic dreams. Buddhism teaches to live with the original human problems such as pains of birth, growing old, suffering from illnesses or diseases, fear of death, separation from loved ones and unfulfilled desires. And children may not respect or support old parents. One should not take anything granted. Thus, depressive experiences would be accepted matter of factly as something ordinary we have to face as long as we live but not as an illness or disease as Obeyesekere (1985) pointed out. One has to go on living even while depressed. Elderly Korean immigrant informants in the USA indicated that they generally understand depression as a mood rather than an illness and believe that one can will oneself not to be depressed. Strong emotions and depressive experiences have potential to disturb and injure bodily equilibrium. It is believed that when upset or in psychological shock, fire is ignited in certain parts of body. Mind-body interrelation works as a holistic system. It is believed that extreme emotions can be regulated by self-cultivation so that inner peace, bodily health and interpersonal harmony can be maintained. The services of professional mental health care providers are not often used because of lack of knowledge about these services, lack of money, language problems, and value and cognitive differences that would interfere with successful psychotherapy. Also, Koreans stigmatize depression, and some may tend to under-diagnose it. For example, one informant diagnosed with major depression by KDIS (Lee et al. 1986), did not perceive depression or illness in her condition. Pathological signs and symptoms are often perceived as phenomena of aging so that Korean elders take care of themselves most of the time instead of referring to biomedical medical services. These factors increase the likelihood that Koreans in the USA would use methods of emotional self-care rather than mental health treatment to address sad and depressive experiences. Although they use the same term, the meaning of 'depression' (woo wool jeung) for some informants differs from major depression (diagnosed by DIS-HI). 'Depression' was explained as being a condition that is related to or coming from a narrow-minded personality or a lack of self-cultivation. It tends to be perceived as a normal phenomenon. Thus, informants seem to think that self-help is enough to renew them from their temporarily weakened state of body and mind. Both the informants who understand depression as mood or non-illness and those who said depression would result in grave consequences such as death also claim there is value in self-help.

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Koreans believe that they find themselves within others, and they expect that being understanding, helpful and kind to others will be a source of happiness. Also, there is a traditional belief that if one does good to others, even more good will return to oneself. They appear to expect to benefit automatically from being harmonious with nature and authorities. Elderly immigrants may expect others to know or understand their position, needs, or wishes without their expressing them explicitly, and they may experience painful feelings of betrayal if their needs are not met. However, adult children and others may have difficulty knowing what their older relatives need because of intergenerational differences and changes in values since immigration. Also, elderly Koreans may expect to be self-sufficient within the extended family and choose not to share emotions or problems with close family members. Elderly Korean immigrants often accept things as they are in the interests of group harmony although that might not necessarily be beneficial to them. This can then lead them to be passive and neglect their own desires or needs, since they suppose that behaving that way is accepted respectfully in their sociocultural context. Others are important as well as self, if not more. Koreans refer their children as their own hands and feet or bone and flesh to emphasize their inevitable interdependency and closeness. Korean elders exist in relative to others so that holism, systematic interrelationship and harmony within self, among others in natural and cosmological sense. Typical traditional medical care regimens are not the essential treatment beliefs and practices but are supportive means. The most important selfhelp element is nature-oriented non-doing derived from Taoist teaching, and self-cultivation and discipline derived from Confucianism, along with other religious and sociocultural influences. The aim is to reach ultimate harmony with persons and the nature. The self is seen as an educable and moral entity. Koreans in their old age reminisce and reflect about what has taken place in their lives to evaluate and strengthen what they are and what they can do in relation to sadness and depression. They use a variety of ways to relieve themselves of depressive experiences, from taking traditional medicines, reading scriptures, meditating, reminiscing, singing, listening to music, traveling, and seeking advice to just talking or confiding. They are very familiar with renewing the self by contemplating the fresh and serene nature alone or with a few close persons. And they may need and appreciate the serenity for change even more because they live in an extended family setting without privacy all the time. However, the cardinal aim of self-help among elderly Korean immigrants is to make peace with self and others by becoming a natural cosmological ethical moral and spiritual being through self-cultivation. Korean elders genuinely enjoy the nature spontaneously, esthetically, sentimentally, sadly and yet peacefully. Sometimes they walk endlessly with

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self absorption as they meditate or reminisce sometimes melancholically and sometimes joyfully. Eventually, the nature and self become one in perfect harmony. Korean elders love to sing and listen to songs and music. Music plays a great role in self-solace and relaxation. Koreans are particularly considered music lovers. Music radiates love and grace (You 1994). Music seems to transform hate to love and harmony so that music has healing power. You (1994: 475) related music with rhythm and rhythm can be experienced and hypothesized 'divinely inspired but what is here generalized as the intensified feeling of rhythm engenders a vital force.., perhaps enhancing one's immune system by facilitating the production of endogenous opioids or some other internal therapeutic substance ...'. Generally, elderly people tend to become more religious and spiritual. And they may expect some solace and mercy from supernatural power when confiding through prayer. According to Koenig & Meador (1996: 109) persons admitted to the medical and neurological services were screened for depressive symptoms and asked how they managed to keep themselves from getting depressed over their physical problems. The most predominant answer, offered by 36% of the patients, was religion. Taoism, Buddhism, and Confucianism influence Koreans to generate holistic health and generate the infinite mental potential inherent to humans through psychological coping. Kim & Rhi (1976) specifically noted that the Tao guides the self to perceive and recognize its internal and external world realistically, to liberate the whole self from all emotional bondage, including existential and pathological anxiety, through a healing process. The aim is to become more truly human by discovering and cultivating the self and reflecting it to humanity as a whole, to be shared with others. Rifkin (1995) stated under the title of 'A Satisfying Conclusion' that old age can be prime time for spiritual growth. Spiritual well-being is viewed as a crucial element of successful aging. The purpose is to turn the burdens of old age into the triumph of spiritual completion. Old age is often synonymous with a loss of control - over body, mind, status and environment. Coming to term in old age is not giving up. Rather, it is seen as doing the inner spiritual work of letting go of control. That allows you to live creatively, freely and spiritually. One can dive fully with joy, hope and courage for and with self, family and friends without fear, guilt and shame. Use of self-care methods to address feelings of sadness or depression may increase elderly Korean immigrants' sense of control, and thus improve their overall well-being. Ch'enyom, a strategy traced back to Buddhism that involves an intentional 'giving up' of expectations in situations of interpersonal conflict or emotional distress, is recognized in Korean culture as a

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form of yielding that increases one's sense of control and morality. And it brings greater inner joy by resolving emotional conflict and distress. Also, it brings understanding, sympathy, empathy, dignity, respect, grace, and deference from significant others, especially from family members, which are very important factors to promote and enhance satisfaction and meaning in life. For example, if their dignity is disturbed, they may be ashamed of themselves, very upset and depressed. Ch'enyom is a virtue because it leads to a high state of understanding and tolerance. It is a means to overcome conflicts, anger, or agony as the paradoxical result of being exposed to emotional, mental and physical suffering, and meeting them with yielding and a degree of self-sacrifice. It creates peace with self and others. The Korean informants learned ch'enyom as a way to live with others, to care for and nurture them with high social, ethical and moral standards. Although the concept derives from Buddhism, it has easily been assimilated into Korean Christianity as well. People who are considered wise and mature, with various life experiences, are known to ch'enyom naturally. Some of the more insightful informants differentiated ch'enyom from dannyom: Ch'enyom is resolving conflicts with understanding and reconciliatory spirit but dannyom is forced and reluctant accepting with anger and frustration. Those people who could practice ch'enyom are considered more religious, mature, giving, and capable of sacrificing themselves for others who cannot possibly reciprocate. Ch'enyom is a non-doing, but it is a very active holistic process and empowers self and people around the self. People who are able to practice ch'enyom are holistically healthier than those who have difficulty reaching that realm. Thus, ch'enyom is considered a higher-dimensional form of self-care, a dignified internal and interpersonal victory for oneself and one's circle which averts crises and increases the harmony of interpersonal relationships. It is the most highly regarded form of self-help. The synthesis of consciously and unconsciously acquired multiple religions empowers elderly Koreans to be confident in taking care of themselves and may impart a sense of belonging and protection even in the absence of tangible support. It is that multiple religious influences open wide avenues of self-help and support. However, if self-care strategies do not alleviate depressed feelings, elderly Korean immigrants may not see the use of Western-oriented mental health care as an option. Medication is not generally sought or used to treat depressive experiences. Some informants say: The medicine doesn't work. The cure is to make them happy but who would do that? There is no facility for that. You can't cure depression with drugs. It's not medicine but to make pleasant things round him. Drugs don't work. They would make your mind unclear.

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However, traditional medicine or non-medicated remedies are practiced by some informants for systematic, physical and mental efficacy. Also, suggestive care such as 'It is up to you. If you want to remain depressed, you can be depressed, but, if you do not want to, then you will not be depressed', is well used. Elderly Korean immigrants take care of themselves with holistic and pluralistic remedies that combine religion-based strategies, and popular and traditional Korean medicine with other self-care techniques. Basic hygiene, eating well, and sleeping well are very important. There are similarities and differences in self-care beliefs and practices among different cultures which may vary in terms of degrees. There may be individual differences due to a variety of reasons, such as sociodemographic factors, societal changes, or acculturation. When it comes to self-care for depression, most people combine bodily care, singing, listening to music and exercising with, verbal, artistic recreational or interpersonal care. Music is very much loved by the informants, perhaps because music brings order within the self and spiritual well being. Some people may tend to do more of one kind of care, some others do other kind of care. Care using all senses is practiced to systematically refresh the naturally creative holistic human being. Korean elders reveal themselves in the process of enhancing greater harmony and adaptation so that often the individual self is invisible or integrated into group goal attainment. What others benefit from and think are more important than the inner self. Self-care seems to be a process of strengthening self, taking more responsibility to be independent from others and still contributing to all inclusive harmony and empowerment of those in the circle. In terms of efficacy, the informants mentioned: 'family got close', 'loving, good and kind hearted', 'care more for each other', etc. Korean elders constantly make the effort to introspect and reflect upon the self to search for areas for cultivation of the human mind, emotions, and ethical moral areas, especially in their family and community context, to develop a larger self and to overcome conflicts within themselves and with others. The cardinal method used by Korean elders is ch'enyom, based on their years of enduring and painstaking self-cultivation and self-discipline. If the small number of depressives uncovered in our sample is any indication, it seems to be working quite well for the vast majority of them.

Acknowledgments The National Institute of Aging supported this research project on depression. I am indebted to the Korean elderly informants for their patience and kindness. I would like to express my sincere gratitude to Dr J. Neil Henderson for his

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kind and insightful guidance. I thank the anonymous reviewers for their valuable suggestions and comments. I am very grateful to Se Kang, Irene Marsh, Brian Deevey, and Terilee Edwards-Hewitt for their editing of this paper.

References Armon-Jones C. (1986). The thesis of constructionism. In: R. Harre (ed.), The social construction of emotions (pp. 32-56). Oxford, UK: Blackwell. B aik S.C. (1979). The meaning of psychotherapy and its application in Korean society, Korean Society and Culture 4:273--313. Borgman A. (1994). Area's Asian Americans step up political activism: Korean community flexing fledgling muscle, Washington Post, 1 November 1994, A1, A10. Chen E.M. (1989). The Tao Te Ching: A new translation with commentary. New York: A New Era Book. Cheung F.M. (1987). Conceptualization of psychiatric illness and help-seeking behavior among Chinese, Culture, Medicine and Psychiatry 11: 97-106. Chin L.C. (1993). Toward a psychology of difference: Psychotherapy for a culturally diverse population. In: J. Lau Chin, V. De La Cancela & Y.M. Jenkins (eds.), Diversity in psychotherapy: The politics of race, ethnicity, and gender (pp. 69-92). London: Praeger. Cohen S., Tyrrell A.J. & Smith A.P. (1991). Psychological stress and susceptibility to the common cold, New England Journal o f Medicine 325: 606--612. Deuchler M. (1983). Preface. In: L. Kendall & M. Peterson (eds.), Korean women: View from the inner room. New Haven, CT: East Rock Press. Engel G.L. (1968). A life-setting conductive to illness: The giving-up, given-up complex, Annals of Internal Medicine 69: 293-300. Engel G.L. (1971). Sudden and rapid death during psychological stress: Folklore or wisdom?, Annals of Internal Medicine 74: 771-782. Engel G.L. & Schmale Jr. A.H. (1967). Psychoanalytic theory of somatic disorder: Conversion, specificity, and the disease onset situation, Journal of the American Psychoanalytic Association 15: 344-365. Folkman S., Lazarus R.S., Scott P. & Novacek J. (1987). Aging differences in stress and coping processes, Psychology and Aging 2: 171-184. Good B.J., Good M.D. & Moradi R. (1985). The interpretation of Iranian depressive illness and dysphoric affect. In: A. Kleinman & B.J. Good (eds.), Culture and depression (pp. 369428). Berkeley: University of California Press. Hsu C. (1972). Koryo togyong. Seoul: Asca Munhwasa. Kim H.A. (1994). Cultivation of mind and heart in Confucian culture: A brief interpretation, Academy Forum: The American Academy of Psychoanalysis 38(1-2): 8-10. Kim H.J. (1972). Myung shim bo gam. Seoul: Myung Mun Dang. Kim K.I. (1991). Psychoanalytic interpretation of Korean traditional culture: Myths, shamanism, and religious experiences. Seoul: Gyo Mun Sa. Kim K.I., Li D., Jiang Z., Cui X., Lin L., Kang J.J., Park K.K., Chung E.K. & Kim C.K. (1993). Schizophrenic delusions among Koreans, Korean-Chinese and Chinese: A transcultural Chinese delusion of religious or supernatural matters, The International Journal o f Social Psychiatry 39(3): 190-199. KJm K.I. & Rhi B.¥. (1976). A review of Korean cultural psychiatry, Transcultural Psychiatric Research Review 13:101-114. Kim Y.J. (1976). The wanderer Kim Saat Gaat's poems and interpretations. Seoul: Hanguk Mun Wha Sa. Kleinman A. (1980). Patients and healers in the context of culture. Berkeley: University of California Press.

254

KEUM YOUNGCHUNG PANG

Kleinman A. (1986). Social origins of distress and disease. New Haven: Yale University Press. Koenig H.G., George L.K. & Siegler L. (1988). The use of religion and other emotion-regulating coping strategies among older adults, The Gerontologist 28(3): 303-310. Koenig H.G. & Meador K.G. (1996). Geriatric mental healt care, Geriatrics and Gerontology Education (in press). Lee M.H., Lee H.Y., Min S.K., Kim K.H., Kim S.Y., Song D.H., Shin J.H., Park M.H., Bae A. & Sung K.Y. (1986). Development of Korean version of the NIMH Diagnostic Interview Schedule and its validity test - Kangwha Psychiatric Epidemiological Survey (1), Neuropsychiatry (Korean) 25(2): 300-313. Lee U.Y. (1988). New Koreans: To where and why are they running? Seoul: Munhak Sasang Sa. Marsella A.J. (1980). Depressive experience and disorder across cultures. In: H.C. Triandis & J.G. Draguns (eds.), Handbook of cross-cultural psychology (pp. 237-239). Needham Heights, MA: Allyn & Bacon. Murphy J.E. (1982). Social origins of depression in old age, Journal of Psychiatry 141: 135142. Obeyesekere G. (1985). Depression, Buddhism and the work of culture in Sri Lanka. In: A. Kleinman & B.J. Good (eds.), Culture and depression (pp. 134-152). Berkeley: University of California Press. Orem D.E. (1971). Nursing concepts of practice. New York: McGraw-Hill. Osgood C. (1962). The Koreans and their culture, 7th edn. Tokyo: Tuttle. Pang K.Y. (1994). Understanding depression among elderly Korean immigrants through their folk illnesses, Medical Anthropological Quarterly 8(2): 209-216. Pang K.Y. (1995). A cross-cultural understanding of depression among elderly Korean immigrants: Prevalence, symptoms and diagnosis, Clinical Gerontologist 15(4): 3-20. Rhi B.Y. (1970). The folk psychiatry of Korea, Neuropsychiatry 9: 35-46. Rhi B.Y. (1974). Analysis in Korea. In: G. Adler (ed.), Success and failure in analysis. Proceedings of the 5th International Congress for Analytical Psychology (pp. 136-143). New York: Jung Foundation. Rhi B.Y. (1983). Korean ethos: Hangukin of Yunriguan. Seoul: Korean Cultural Research Center (Hanguk jungshin munhwa yunguwon). Rhi B.Y. (1986). Confucianism and mental health in Korea. In: Thepsycho-cultural dynamics of the Confucian family: Past and present (pp. 249-276). International Cultural Society of Korea. Rifkin I. (1995). A satisfying conclusion, Washington Post, 25 March 1995, Religion, B.7. Robins L.N., Helzer J.E., Croughan J. & Ratcliff K.S. (1981). National Institute of Mental Health Diagnostic Interview Schedule: Its history, characteristics, and validity, Archives of General Psychiatry 38: 381-389. Rodin J. (1968). Aging health: Effects of the sense of control, Science 233:1271-1276. Schmale Jr. A.H. (1972). Giving up as a final common pathway to changes in health, Advances in Psychosomatic Medicine 8: 20--40. Schmale Jr. A.H. & Engel G.L. (1967). The giving up-given up complex illustrated on film, Archives of Behavioral Psychiatry 17: 135-145. US Bureau of the Census (1990). Census of the Population. Washington, DC: US Department of Commerce. Unschuld P. (1985). Medicine in China: A history of ideas. Berkeley: University of California Press. You H. (1994). Rhythm in Chinese thinking: A short question for a long tradition, Culture, Medicine and Psychiatry 18(4): 463--481. Yun H. (1976). The Korean personality and treatment considerations, Social Casework 57(3): 173-178.

Address for correspondence: Keum Young Chung Pang, Howard University, College of Nursing, Washington, DC 20059, USA