The Vietnamese represent sixty-seven percent of the nearly 550,000 Southeast Asian refugees who had been resettled in the United States as of September 1981 (U.S. DHHS 1982:15). The San Francisco Bay Area currently has a Vietnamese refugee population of approximately 30,000. About one-half of the Vietnamese refugees are ethnic Chinese (field notes, November 1982).


A large percentage of the Vietnamese refugees in the United States (about 145,000) fled Vietnam within weeks of the fall of Saigon in April 1975 and represent some of the earliest arrivals to the United States. From ten to fifteen thousand left within a few days prior to the collapse of the Thieu government; another 68,000 Vietnamese and Americans were evacuated by way of massive airlifts during the last days of April; and an additional 40,000 to 60,000 fled in commandeered aircraft and in ships and small boats (Liu. 1979:1, 13-14). A second large wave of refugees, comprised of more than 85,000 “boat people,” fled Vietnam during the last months of 1978; the majority (about sixty percent) of these boat people were Chinese Vietnamese (Montero 1979:70-71).

The earliest Vietnamese arrivals were relatively well-educated and predominantly from urban backgrounds. According to early reports (Liu 1979), nearly a third of the household heads surveyed indicated that they had been in the medical profession or in professional, technical, or managerial positions in Vietnam. Seventy percent had also lived in Saigon prior to their evacuation. Only five percent indicated rural backgrounds or occupations in farming, fishing, or forestry. According to these same reports, the earliest arrivals were also predominantly Catholic (55%). The Vietnamese who indicated that they practiced ancestor worship were mainly confined to the Buddhists and Confucians, who together comprised about a third (39%) of those surveyed. About two-thirds also also spoke English and over forty percent spoke French.

Subsequent reports on later refugees (i.e., those who arrived after 1975-76) suggest that the Vietnamese refugee population is somewhat more

diverse and less “westernized” than the earlier studies may have indicated. For example, the “boat people” and later refugees are reportedly less educated, less proficient in English, and include a larger percentage from rural fishing and farming villages. The group also includes a substantial number of ethnic Chinese. (Aylesworth 1980:66-67; Carlin, n.d.; Starr, 1981; Center for Applied Linguistics, n.d.)

Medical Practices in Vietnam

Several medical traditions co-existed in Vietnam. These include western medicine, traditional Chinese medicine (ong lang), and folk medicine and health concepts centering on the ill effects of phong (“wind”). As elsewhere in Southeast Asia, there were also religious views which linked illness to supernatural intervention.

Western Medicine and Psychiatry

Western medical services were first introduced in Vietnam prior to the 1800's by European and American missionaries and later expanded during the French colonial rule (1883-1946). During this period, the French established public health services, hospitals and clinics, and a school of medicine at the University of Hanoi. In South Vietnam, faculties of medicine were subsequently added to the University of Saigon and, in 1961, to the University of Hue (Smith 1967:129-131). By the fall of the Thieu government in 1975, South Vietnam reportedly had 2,000 registered physicians. For a population of 18 million, this theoretically meant a ratio of physicians to patients of 1 to 9,000. Because three-quarters of the physicians served in the army, there were probably even fewer available for the civilian population (Tung 1980:32-33). By contrast, there was a fairly large number of practitioners trained in traditional Chinese medicine. According to one estimate, there were 4,600 such practitioners in 1965, six hundred of whom resided in Saigon (Smith, pp.129,132). According to Rieu (n.d.), fifty percent of the rural and urban population continued to resort to these doctors of Chinese medicine.

The shortage of western-trained medical personnel also applied to the field of psychiatry. According to Tung (p.75), the medical personnel in this field included three clinical psychologists; three psychiatric social workers;

psychiatric nurses who were trained on the job; and eight full-time psychiatrists, who were responsible for two in-patient facilities and about 2,000 hospital beds. It was not unusual for patients to have tried some form of traditional treatment before entering a psychiatric facility or consulting a western-style physician (McKinley 1966:423; Tung, p.74). Often these physicians were the final choice, resorted to only after traditional cures proved ineffective and the patient was no longer manageable in the home or the community.

Traditional Medical Practices

Traditional avenues for the treatment of mental disorders can be categorized according to one of three disease models. Tung (1980) describes these as the “Am Duong Model,” the “Organic Model,” and a collection of beliefs centering on supernatural beings. The latter reflects a mixture of folk religion, Buddhism, Confuciansim, and Taoism.

Am-Duong Model

The Vietnamese concepts of am and duong are based to a large extent on Chinese traditional medicine and the belief that illnesses are caused by im-balances in a complex system of correspondences. All phenomena in the universe (including the organs of the human body, the seasons and cardinal points, and the emotions) are incorporated into this classificatory system. The basic categories are yin (am) and yang (duong). Associated with yin are foods characterized by their sour or pungent taste; the seasons of winter and autumn; the hours between noon midnight; cold and coolness; and human organs such as the liver, heart, and spleen (Lock 1980:32; Porket 1974:23-29).

Illnesses, depending on their properties or symptoms, can also be classified in terms of a deficiency or excess of yin or yang. The system applies to both physiological and mental illnesses. For example, pimples are thought to come from an excessive amount of heat which erupts through the skin (Tung, p.13). Delirium and agitated psychoses are thought to be caused by a preponderance of yin (p.56). Physiological imbalances (i.e., excesses or deficiencies of yin or yang) can be caused by internal influences (e.g., one's emotional state) or external influences (e.g., sudden climatic or seasonal changes), which work within the body to obstruct the circulation of ch'i (vital energy) or one of

its variants (e.g., blood or hsüeh). One method of clearing obstructions is the application of acupuncture to strategic points of the body. Another way of remedying the imbalance is to prescribe herbs or aliments which can offset the imbalance by virtue of their yin or yang attributes (Lock, pp.35-37).

Organic Model

The Organic Model sees mental illness as a function of the nervous system. According to Tung (p.55), the Vietnamese, like the Chinese, describe neuroses as a “weakness of the nerves” (than kinh suy nhuoc) and psychoses as a “turmoil of the nerves” (than kinh thac loan). In practice, “weak nerves” seems to be a common complaint, signifying minor mental disorders ranging from anxiety to depression and sometimes including mental retardation and mental deterioration. Medicine (e.g., an appropriate nerve tonic or tranquilizer) is usually prescribed to treat such conditions.

Supernatural Model

According to Tung (p.74), supernatural intervention has been the most persistently held cause of mental illness as well as its most popular form of treatment, regardless of the patient's level of education and sophistication. In Vietnam, folk beliefs are similar to other Southeast Asian groups such as the Hmong and Mien in that they encompass a body of spirits with both harmful and protective tendencies. The malevolent spirits are capable of inflicting illness, insanity, or even death by taking one of the souls or “vital spirits” which the Vietnamese believe sustain and give life to the human body (Hickey 1964:76).

Two opposing types of supernatural beings, or spirits, are the tien, deities who are believed to have the power to protect individuals, and errant spirits. The latter are the spirits of individuals who have died without benefit of an ancestral cult in their honor (p.76). The importance of the cults resides in the belief that individuals can attain happiness in the after-life only if they are properly venerated by their descendants (p.88). Cult maintenance is the responsibility of members of the same patrilineage (toc) and involve appropriate ceremonies and offering in honor of deceased ancestors, usually up to three generations in ascent from the patrilineal head. Ma troi are a type of errant spirit, normally the ghosts of people who

have drowned but whose bodies have not been recovered. Like others who have died violent deaths or have no families to carry on observances in their behalf, ma troi are destined to wander the earth, causing harm to the living, until they can be restored to the family tomb or to the ancestral altar (p.78).

Vietnamese communities had several types of religious healers who were able to prevent or treat supernaturally caused illnesses. These include spirit mediums, “sorcerers,” and Buddhist priests and lay monks. Hickey describes two such healers in a small village located outside of Saigon. The ong thay phap (“Masters of Sorcery”) were healers who derived their special powers to invoke and exorcise evil spirits from patron deities who were the center of cult worship. According to Hickey (pp.78-80), one of the village ong thay phap specialized in curing mental disorders. The usual procedure was to obtain a sample of blood from the patient and use it to write a special formula which had the power to frighten away the afflicting spirit.

Hickey (pp.64-66) also describes two village lay monks (cu si) who served as healers. The elder cu si, who had learned his healing arts from monks in southern Cambodia, employed amulets and medicines for physical ailments and exorcism for cases of “insanity.” The younger cu si specialized in disorders associated with childbirth.

Ong dong and ba dong are spirit mediums associated with the popular cult, chu vi, which honors the spirits related to the goddess Lieu Hanh and the fourteenth century cultural hero, General Tran Hung Dao. Cult rituals focus on communication with either the spirits or with the souls of ancestors. Ong ho, usually associated with a particular pagoda, derive their powers to protect individuals against misfortunes and disease from the deity Quan De or by his acolytes, Quan Chau and Linh Hau (LeBar, p.170).

A Vietnamese Religious Healer in the Bay Area

The Vietnamese healer who was interviewed for the study is a Buddhist priest attached to a large temple in San Francisco. The temple was founded in 1978 by four Vietnamese refugees and has a congregation of from 500 to 1,000 members, representing all age groups. About fifty percent of the congregation has been in the United States for five years or longer. Both ethnic

Vietnamese (who comprise about 60% of the congregation) and Chinese Vietnamese (40%) attend the temple, along with a small number of Caucasian Americans.


The temple is open from 9 a.m. to 11 p.m. on weekends and from 5 to 11 p.m. on weekday evenings. In addition to the interviewee, three other monks reside on the premises of the three-story building which serves as the temple. The second floor has been converted into a worship hall; the third floor into the monks' residence; and the ground floor, into a general activities and dining area. The temple is located on a busy thoroughfare, within walking distance or easily accessible by public transportation for the majority of the congregation. Elderly Vietnamese and minors who live outside of San Francisco rely on family members for transportation. The temple is one of several fairly large Vietnamese Buddhist churches that have developed in San Francisco. A number of smaller temples have also been formed within the last few years. The temples are seen as major forces in the rebuilding of Vietnamese communities in the United States.

The temple which provides the setting for many of the interviewee's activities performs a broad range of functions within the Vietnamese community. In addition to weekly Vietnamese language classes, the temple offers lectures on child-rearing and parenting skills; for younger members, lectures on how to get along with parents; and for couples and those contemplating marriage, lectures on marital relations and roles. The priest sees these lectures as ways of bridging the cultural and generational gaps that are developing within Vietnamese families. Meditation is also taught as a way of acquiring spiritual strength and discipline.

On a typical Sunday, sixty to eighty members are likely to be at the temple. The younger children may be playing in the building, while adults stand in conversation or prepare Sunday lunch. Other members may be sitting in prayer or making offerings at the altar. Several people may be sitting in the monks' quarters on the third floor, waiting to talk with the priest. On one visit, a man who had received a telegram from Vietnam informing him of his brother's death waited to discuss funeral arrangements and to share his sorrow with the priest. Another woman waited to discuss her worries about relatives still in Vietnam. During one of the interview sessions, a Vietnamese

herbalist dropped by with medicine for one of the members of the congregation. For individuals who are depressed or more severely disturbed, the interviewee offers assitance that ranges from social casework to spiritual counseling and rituals to exorcise possessing spirits.

The Vietnamese Priest

The interviewee has been in the United States for about six years and speaks English as well as Vietnamese. He is also fairly fluent in Mandarin. Now in his early forties, he began studying Buddhist doctrine from the time he was a young child. It was in Vietnam that he also learned special Buddhist rituals for those who were possessed by spirits or ghots. Curious whether some of the principles of western psychology could be applied to his own work, he recently enrolled in a psychology course at a local university.

The priest speaks with deference about his position in Vietnam and this country. As a monk in Vietnam, he feels that he was surrounded by a number of teachers who were older and more experienced in helping people. In the United States, he feels reluctant to be called a “spiritual leader” and prefers to consider himself a friend to those who seek his help. In addition to its other functions, he sees the temple as a “place where people can come to talk about their problems.”

Role in the Treatment of Mental Illness

The priest recognizes many factors which may contribute to mental illness among the Vietnamese refugees. Generally, these are related to changes in the economic and material status of the refugees and to changes that threaten their “spiritual” life. Among the changes are the loss of traditional forms of support. For believers, this might be the lack of Buddhist temples in their new environment and, for many of the refugees, regardless of faith, the loss of family members, who may have died or been left behind in Vietnam. Once settled in the United States, he believes that generational and cultural gaps may develop which further divide families. For example, a growing source of tension may be the wife's newly gained status as a wage-earner. The lectures (on child-raising, marital roles, etc.) are a way of strengthening the family by increasing each of the members understanding

standing of the changes that may be occurring. In terms of the medical model, much of what the priest does (e.g., by way of lectures and services for the spirits of deceased relatives in Vietnam) might be seen as preventative mental health.

A clear picture of how often the priest works with individuals whom he might consider “mentally disturbed” was not obtained, but three recent cases are described below. Treatment in such cases seems to involve several phases. The first is to relieve the immediate symptoms; for example, in instances of spirit possession, to release or exorcise the possessing spirit. The next phase is directed toward placing the individual back in the community. In some cases, this may temporarily be the “sheltered community” of the temple. A third step is to provide individuals with a philosophic, or religious, framework that will sustain and help them deal with further problems. However, attempts to teach individuals Buddhist doctrine or meditation are postponed until they are in a suitably stable, or balanced, state of mind. According to the priest, individuals who are upset or distraught quickly forget. His approach to people who are in need of help is first to establish himself as a friend or someone with whom the individual can easily speak.

Case Examples

Each of the individuals in the cases described below was referred to the priest, or brought to his attention, by a friend, relative, or social service agency because of what was considered unusual or unacceptable behavior. When asked how he himself might determine whether a person was in need of help or what treatment plan to follow, the priest said he follows a few simple procedures. For example, he observes the person's eyes, facial expressions, and behavior; he listens to the way the person talks; and he asks about their background, family situation, and social environment.

Case of a Fifteen Year Old Girl

A Chinese Vietnamese mother recently brought her fifteen year old daughter to see the priest after the girl began exhibiting what her mother considered “unusual” behavior. Both had come to the United States seven years earlier, and the daughter spoke fluent English as well as some Chinese, which was used at home and with friends. Although she knew Vietnamese, she

had never felt comfortable in the language and, until recently, seldom used it.

When the daughter and mother first visited the priest, the girl conversed in Vietnamese, saying she had forgotten how to speak English. The priest said her hands were trembling and her eyes had a listless look to them. On the girl's second visit, she brought a friend. This time, whenever she mentioned her mother, she spoke in a man's voice. Her mother was referred to by her given name, a sign of disrespect to the Vietnamese. The priest noticed that she often blinked her eyes during the meeting. She complained that she could not sleep well and that neither she nor her mother got along. She often recalled her father who had died in Vietnam two years after she and her mother left for the United States.

Neither the girl nor her mother were members of the temple. The mother had remarried but, with the death of her second husband, began to feel she would bring bad luck to anyone she married.

The priest diagnosed the immediate problem as a case of spirit possession. He felt that the soul of the girl's father had not been able to find peace and was lingering on earth, near his wife and daughter, in order to protect and watch over them. The priest's first step in treatment was to offer a special ceremony for the father's soul so it might find its way to the Buddhist Pure Land. During the ceremony, temple monks offered prayers and incense on behalf of the father's soul. When the chanting ended, a memorial tablet with the father's picture, name, and dates of birth and death was placed beside the main altar, alongside other memorial tablets, so that prayers might be offered in his honor from that time forth. The ceremony was performed about two weeks after the case was first presented and lasted approximately two hours.

From information provided by the young girl, the priest then began contacting people in her social environment who might be able to shed light on the girl's background and present living conditions. The hope was to begin a treatment plan that could draw on this information. In the meantime, he believed it was important to maintain an understanding relationship and to spend time with the young girl and develop her trust. The priest indicated that he does not use “mental illness” when helping those who come to him.


Case of the Ghost-Possessed Woman

The second case, also involving spirit possession, concerned a Vietnamese refugee in her early sixties. She had been in the United States for about three months and had been resettled, with her husband, north of San Francisco. During her first meeting with the priest, she spoke in the voice of the possessing spirit (a young woman who had drowned at the age of nineteen), saying that she was in Hell suffering and needed help. Before a social worker at a local resettlement agency referred her to the priest, the woman had been sent to a western medical doctor for an examination and told she was in good health.

During her first visit to the temple, the woman frequently broke into tears and wept. She complained that she had been unable to eat or sleep properly for nearly two weeks. For about a month, a woman had been appearing in her dreams, saying that she wanted to take the patient's life. Fearful of leaving her home, the patient agreed to see the priest only because of her husband's steady insistence. Although she had no recollection of some of her actions during this time, later interviews indicated that she had been told she was acting very strangely (“crazily”). At the temple, she apparently took food from the altar but, when questioned about her behavior, only answered that in Hell she was poor and hungry. She referred to herself by the name of the young woman who had drowned.

Treatment consisted of a ceremony which lasted about an hour. While the patient kneeled before the altar, offerings of paper money, paper clothes, and incense were made, along with requests by the priest that the possessing spirit no longer torment the patient. Monks at the temple and other worshippers participated, offering prayers for the deceased woman's release and her spirit's passage to the Pure Land. After the ceremony, witnesses indicated that the woman became calmer and was able to give her own name.

At one time, because there were few Vietnamese where she lived, the woman asked that she and her husband be allowed to stay at the temple. The woman now attends every Sunday and, depending on the priest's schedule, may spend several hours in conversation with him. She indicated that she was grateful for the priest's friendship and the support she receives at the temple. She also said that, since the ceremony, she has been feeling much better.


Case of an Alcoholic Young Man

The third case concerns a young Vietnamese refugee who had been in the United States for six years and lived in the neighborhood of the temple. According to the priest, the young man lacked the incentive to work or to earn money because he had no responsibilities for a wife or family in the United States or in Vietnam. When his case was brought to the attention of the priest, through the intervention of a friend, the young man was receiving welfare assistance, drinking up to twenty cans of beer a day and smoking heavily, sometimes as much as ten packs of cigarettes daily. He also refused to talk with anyone and was isolating himself in his small apartment.

The priest's first step in intervention was to break the young man's isolation by encouraging him to accompany the priest on walks to the beach and nearby parks. During this time, the priest said he never directly questioned the young man but used their walks to begin building their relationship. In time, the priest asked the young man to move into the temple, where he could be monitored and observed more closely. On the young man's bedroom wall, the priest posted several reminders. The goal was: “One can of beer and two cigarettes a day.” The third step was to encourage the young man's participation in other activities: he took the man to work at a local factory during the day and also had him help out with work in the temple. Apparently the young man has been following the new regimen and has cut down on his drinking and smoking. He says he feels much happier.