‘In Korea, there is no mental health’: Barriers to treatment

“In Korea, there is no such thing as mental health. One is seen as ‘weak’ if they have a mental health issue. People with mental health issues are seen as ‘crazy’ and the issue is something that must be overcome. It is often seen as a lack of faith in Christ.” My interviewee, Jin-Hee, is a Korean-American mental health professional in the Pacific Northwest of the United States. Born to Korean parents, she was raised in a traditional Korean church community. Given that depression is perceived as a sign of personal weakness, according to Jin-Hee, it is not seen as a clinical issue in Korea. It is, rather, seen as a burden on a family’s reputation.

As stated in my previous articles, South Korea’s suicide rate is one of the highest in the world. This high suicide rate has been attributed to pressures relating to conformity for those in the 20s and 30s, to loneliness, cultural dislocation, and lack of social connection for the elderly. Even so, there remains an aversion to accepting mental health treatment. The barriers to treatment derive from cultural factors like low trust of strangers, the way that an individual’s reputation reflects on one’s family, and lack of awareness and recognition of alcoholism and depression as legitimate medical problems.

While most people who suffer from mental health disorders do not kill themselves, according to Kay Jamison in “Night Falls Fast: Understanding Suicide,” mental disorders, including substance use, are found in almost all individuals who have died by suicide. Increasing the acceptance of mental health and substance abuse treatment will likely help those most vulnerable to suicide while also filling a critical gap in mental health treatment.

Low-trust society

As noted by Michael Breen in his insightful book, “The New Koreans,” many South Koreans are afraid to see a mental health professional because they worry that their medical records will not remain private. People do not “trust in the government’s promise of confidentiality.” Breen discusses how “a chief of police recently admitted that police recruiters regularly check the medical records of applicants.” Breen also notes how on some job application forms applicants are asked to disclose whether they have been treated for psychological illness.

This lack of trust in the confidentiality of medical records naturally leads to issues with trusting mental health professionals. Another Korean-American mental health professional who works primarily with elderly Koreans and Korean-Americans – let’s call her Su-Yeon – confirmed the difficulty in establishing trust with patients precisely because they worry that their personal stories will not remain private. Even without concerns about confidentiality, establishing trust with a therapist is no easy thing. In a society like Korea where the integrity of medical confidentiality is doubted, the barrier to seeing and then trusting a therapist is that much higher.

Jib-dan ei-gi ju-eiu

Many Koreans with whom I have spoken describe Korea as a jib-dan ei-gi ju-eiu society which translates to “group greed”. The concept of “group greed” is directly related to a low-trust society. “Group greed” means that an individual’s important groups (family, alumni associations, one’s team at a company) take precedence over all else and one acts in a selfish fashion when it comes to looking out for these groups. In other words, “looking out for number one” means loyally serving one’s group. One’s group is even more important in Korea given the low trust people hold for their government, made all the worse by this year’s impeachment and removal from office of corrupt ex-president Park Geun-hye. Likewise, South Koreans have very low rates of giving to charities. Charities are often groups disconnected from one’s network of trust (family, alumni associations, one’s team at a company, and possibly one’s church) and thus require trusting a stranger to properly use one’s money as intended. A mental health professional is thus no different from the government or a charity – the mental health professional is outside of one’s immediate groups and thus automatically viewed with suspicion.

While considering the barriers to mental health treatment, I kept coming back to the question of why a more collectivist society like Korea could not provide support for individuals who suffer from poor mental health. If the individual faithfully served his or her groups why could the individual not count on reciprocity in supporting the needs of each individual person?

Chae-mien and the need for therapy

Unfortunately, discussing mental health issues with one’s group makes the person feel ashamed in the presence of their fellow group members. Fear of being a weak link in the group and ruining one’s image in the eyes of others is a major stress itself. As Breen states in The New Koreans, “[the] problem with the group, at least as it tends to work in Korea, is that it leads to people being overly concerned with the views of others.” Maintaining chae-mien, or face, is of utmost importance. And given the inability to trust anyone outside one’s group – even if they are trained professionals (as discussed above) – an individual is unfortunately left to deal with mental health issues alone.

As a non-Korean who can speak Korean I was able to see firsthand the need for an acceptance of a therapist culture. As an outsider who had no ties to either a person’s societal groups or Korean society at large, it was common for people to quickly open up to me and tell me very personal stories that they had never told anyone else. For example, in 2015, I interviewed a retired female art professor to investigate changes in women’s roles and expectations over her lifetime. A two-hour interview ended up extending to over 20 hours and spreading out over five days. The professor divulged details that had haunted her but that she had never shared with anyone in her groups. Through the shedding of many tears, the professor kept saying how great it was to be able to share her thoughts and han (pent up bitterness).

I was connected to this professor through a friend of my mother-in-law named Kyeong-Min. Kyeong-Min was in one of the professor’s professional groups. Naturally, the professor was insistent that I not share any details with Kyeong-Min. Even more telling, however, was the fact that Kyeong-Min told me not to let the professor know how my mother-in-law and she were connected. Kyeong-Min knew my mother-in-law from a beginning level English class. Kyeong-Min would lose chae-mien (face) if the professor knew that her English ability – a social status marker in Korea – was so low. If protecting the truth about one’s English ability to other group members is so important to maintaining face, it is clear the damage a disclosure of one’s poor mental health may do to one’s image in the eyes of their group members.

The permanent taint

The degree to which mental health issues are viewed as a stain on one’s family is further illustrated by how the actions of members of a family taint other members of that family. For instance, my friend Gi-Hyeon wanted to marry his long-time girlfriend, Seong-Yeon. Seong-Yeon’s parents, however, were divorced which was unpardonable in Gi-Hyeon’s parents’ eyes. As if this were not bad enough, Seong-Yeon’s socio-economic background was lower than Gi-Hyeon’s in addition to the fact she was not raised a Christian. Of these three strikes against her, Seong-Yeon could only control one – her religion – although she could not control the religion of her family. Nonetheless, the stain of Seoung-Yeon’s parents led Gi-Hyeon’s parents to deny permission to Gi-Hyeon wed. Gi-Hyeon, after years of going back and forth about whether to disobey his parents and face disownment or break up with Seong-Yeon, ultimately broke up with Seong-Yeon.

Similarly, a good friend of my wife – Myeong-Ha – came from a divorced family. Her long-time boyfriend – In-Jae – also came from a divorced family. In the words of Myeong-Ha, “It was lucky that the person I loved just happened to be from a divorced family too. I didn’t choose In-Jae because of that but I probably couldn’t have married him if his parents weren’t divorced.” A family’s honor is so important in Korea that many married couples who want to divorce will not officially divorce but either live in the same house with an agreement not to be a couple (known as jeol-hon) or, if economically viable, live in separate residences (known as byeol-geo). By not officially divorcing they preserve their children’s marriage prospects.

The stain caused by suicide and mental health issues on a family is no different. According to Jin-Hee, the above-mentioned Korean-American mental health professional, as a youth growing up in a Korean church a member of the congregation killed himself. Rather than rallying around the survivors of the deceased, congregation members distanced themselves. People in the congregation said that the deceased was likely “in hell.” The family became outcasts from the church. Suicide’s permanent stain on the surviving family members left a warning clear for all to see: a mental health issue can ruin a family’s reputation – thus perpetuating the wrongful notion that mental illness is best left inside and untreated.

Medicating through the drink

Al-Jazeera recently labeled South Korea as the country with “the world’s worst drink problem.” In a country with the developed world’s worst suicide problem and low acceptance of mental health therapy, the connection between Korea’s drinking problem and poor mental health outcomes cannot be overlooked. As noted in Al-Jazeera’s fascinating video about the problem, Korean interviewees discuss how alcohol allows them to open up to co-workers and bosses with whom they cannot be intimate otherwise. Likewise, college students discuss how heavy drinking allows them to de-stress from South Korea’s hyper-competitive society.

In Kay Jamison’s informative book about suicide, Night Falls Fast, she notes that “a vastly disproportionate” number of people who suffer from alcoholism and other acute psychiatric illnesses kill themselves. She states that “acute psychiatric illness is the single most common and dangerous trigger of suicide.”1 In Korean, however, there is not a term specifically for alcoholic (someone might refer to being addicted to alcohol, but there is not separate term). A common question when meeting someone new is “What is your ju-llyang?” which translates to “What is your drinking capacity/tolerance?” Dinners that include heavy drinking with co-workers are very common (as the video shows). Refusing to drink, or even trying to take it slowly, is not an option since when one person drinks, everyone must drink to preserve group harmony.

The above examples show that the willingness to drink heavily is celebrated and the refusal to drink is shunned. Consider how regularly drinking 10 or more drinks on a weeknight and going to the work hungover the next day would be viewed in the United States. Far from being praised, this would seriously worry anyone close to the person and if an employer knew, their job may be in jeopardy. In Korea, however, drinking late into a weeknight and working with a hangover is how you live.

Not shockingly, on a clinical level, alcoholic treatment systems are highly underdeveloped compared with the United States. Among the many Koreans I know from my four years in Korea and my Korean family, with few exceptions, the awareness of alcoholism as a disease to be treated is non-existent. If, as Jamison notes, alcoholism is a severe psychiatric disorder that correlates with higher rates of suicide, then a straight line can be drawn between an aggressive drinking culture and a low awareness of alcoholism to poor mental health outcomes and a barrier to mental health treatment.

Not seen medically

Just as concepts of alcoholism are underdeveloped and thus present a major barrier to mental health treatment, depression itself is not viewed as a medical issue. Anecdotally, Su-Yeon, the previously mentioned Korean-American mental health professional, discussed a major aversion to both therapy and taking anti-depressants in part because it is not seen as a legitimate medical issue. Su-Yeon reported that among her elderly Korean clients who take antidepressants, many only take their medication when they feel depressed. In other words, it is seen by many elderly Koreans she works with as like Tylenol for depression. For antidepressants to be effective, however, daily dosages are critical.

Statistically, while Koreans have the highest suicide rate amongst OECD countries (those that are economically developed), they are tied for last place in the rate of antidepressant use. As psychiatrist Dr. Jeff Sung states, “Antidepressants have correlational data to suggest decreases in suicide rates associated with increasing antidepressant use.” Dr. Sung acknowledges that this fact does not mean there is causation between antidepressant use and lower suicide rates. However, correlational data combined with powerful anecdotes about the transformational powers of medication treatment of depression means a wider acceptance of antidepressants could make headway in addressing a major risk factor for suicide in Korea.

Medicine – visiting doctors and taking prescription and over the counter drugs – is, however, very common in Korea. In fact, Koreans often will go to doctors just when they have a cold. Anytime I was sick with a cold or the flu people reflexively said to me “Byeong-won-ai ka bwa” (Go to the clinic/hospital). This habit of seeking medical treatment exists in part because a doctor visit and prescription drug prices in Korea are cheaper than the United States. This habit also shows the degree to which medicine outside the mental health field is widely accepted in Korea. It is the inability to see mind and body as connected that is the block for accepting mental health as just another field of medicine.

Hope on the horizon?

The positive news for Korea, however, is that the number of psychiatric medical centers has increased considerably over the last two decades. The government and many individuals are indeed taking the problem of mental health seriously. To get over the substantial cultural barriers to mental health treatment, however, South Korea’s government should use a page out of the playbook of Park Chung-Hee. Park was South Korea’s president during their economic transformation of the 1960s and 1970s. Prior to the 1960s and 1970s, women in Korea did not usually receive an education and working outside the home was shunned. Families hoped and prayed to have sons. However, Park’s government spent significant resources on advertisements encouraging investment in women’s education and economic opportunities. Educating daughters to an equal level of men was presented as a patriotic duty of families. In part thanks to this campaign, people like my wife, her sister, and millions of other women are now surpassing men in Korea in some educational categories. Moreover, according to many Koreans with whom I have spoken, daughters are now preferred by many families (the most common reason given was a women’s greater care for parents later in life).

The campaign to improve educational access for women proves that despite being a conservative culture with frustrating trends like those described above, Korea’s traditional culture is changeable. As noted in my previous articles, Korea has gone from a rural to an urban society and from an extremely impoverished to a very wealthy society within the last half-century. The resulting cultural changes have left no family untouched. A concerted public relations effort by the government that takes advantage of Koreans’ openness to medical treatment for physical ailments, combined with Korean’s openness to change as part of a patriotic duty, would be well worth trying. This is, after all, the nation where women sold their family’s jewelry during the late 1990s IMF debt crisis to financially support their government in a financial crisis. The solidarity of Koreans in a crisis should never be underestimated. In a nation with a persistently high suicide rate, Korean attitudes toward mental health treatment are without a doubt a threat to the nation. Changing those attitudes will require the mobilization of the population like in any past national campaign or crisis.

– By Chris Juergens

1 It is important to note that Jamison does state that while those with acute psychiatric illnesses are much more likely to kill themselves, “most people who suffer [from those illnesses…] do not kill themselves […]”