A formal portrait of Sok-ki and his mother. Photo courtesy.

The Unraveling of hyo-do: Behind South Korea’s Elderly Mental Health Crisis

While roasting pork belly and kimchi accompanied by the ubiquitous Korean liquor soju, my friend Sok-Ki’s widowed mother called him to see when he would be home. In the most respectful Korean (Korean has multiple distinct levels of speech, determined by the context and with whom you are speaking), he said “Yes, mom, I won’t be too late. Yes, is there anything you need? OK, great. Take care, I’ll see you soon.”
For many Korean children, it is more common to use the intimate form of speech one would use with friends when speaking to one’s mother – but not with the ever respectful Sok-Ki. Over beers after dinner, mom called again. Same respectful, patient response. An hour later, at the early hour of 10:30 for a Friday night in Seoul, Sok-Ki’s mom rang again. Before picking up, he said to me, “Looks like I have to run. Sorry.” Answering the phone, he told his mom he would leave right away before she could ask.

The tension of hyo-do

For someone in his early forties, Sok-Ki’s devotion and willingness to serve his mother in lieu of pursuing personal desires is truly unmatched. He epitomizes the Korean concept of hyo-do (filial piety) which is an expression of jeong (love and sweetness). He is unmarried, so not having his own family in a sense makes it easier to take care of his mother. It may also hold him back from possibly finding a partner of his own. To escape Seoul’s pollution, Sok-Ki moved with his mother from their residence in the city to a suburb far north of the city. The long commute, combined with a full-time job as a web designer and the caregiving needs of his mother, made dating difficult.

Following the Korean tradition of caring for one’s parents, Sok-Ki’s older brother, for instance, had formerly lived with his parents along with his wife and children. However, desiring more space and privacy for his family, he decided to leave – creating a major rift with his parents. When I asked Sok-Ki about his brother’s actions, he said he understood both his brother’s and parents’ opinions and just said it was difficult. Balancing personal desires with the expectations of one’s family is never an easy task, he said.

The irony of Sok-Ki’s situation is that when his father passed away in 2012, Sok-Ki felt ashamed that as a son he had not married. His father’s eyes were open when he died and Sok-Ki saw this as a sign that his father could not rest peacefully given the fact he was unmarried. He described his unmarried status as a form of bul-hyo, or lacking in filial piety. When Sok-Ki told me this, I reminded him that he had been as responsive to his father as he was to his mother. He brushed aside my reassurances, focusing again on where he had failed. His han, or bitterness, ran deep.

The tensions in Sok-Ki and his family’s story exemplify why many older South Koreans struggle with happiness and have a high suicide rate of roughly 50 per 100,000. As explored in my previous post, Koreans in their 20s and 30s are expected to obtain high-paying jobs that overwork them, to marry, and to have children. Fulfilling these expectations takes tremendous personal sacrifice especially considering the cost of education in Korea (while public schools are nearly free, after-school academies are ubiquitous and seen as the key to academic success). Given the human and financial cost of fulfilling those expectations, continuing the Korean tradition of living with and financially supporting one’s parents is too great for those like Sok-Ki’s brother. Moreover, a much stronger culture of individualism has developed in Korea, of which having one’s own home is an example. Paradoxically for Sok-Ki, however, living with and taking care of his mom was a major impediment to fulfilling the other family expectation of marriage.

As traditional expectations compete with increasing individual desires, hyo-do naturally suffers in many families.

Social isolation, poverty, and the generation gap

The competing and conflicting expectations on the grown children in Sok-Ki’s family directly relate to the poor mental health outcomes of the elderly. Mothers as lucky as Sok-Ki’s are becoming rarer and rarer. Many elderly people, living alone after a spouse dies, die alone. This is especially true for the elderly living in the countryside from which their children have left for the city (South Korea is over 90 percent urban, with much of this growth coming in the last few decades as Korea has modernized).

For those who move to the city with their grown children, a severe sense of dislocation and social isolation can take root. South Korean author Shin Kyung-Sook’s novel “Please Look After Mom” details the difficulty an elderly mother has in connecting with her urbanized children, comprehending their vastly different lifestyles, and navigating modern city life despite the efforts of her children to look after her. Ultimately, the mother – who is typically illiterate for someone of her generation born in the 1920s or 1930s – is lost in the Seoul metro and never found, a symbol of the urban dislocation amongst many elderly. Her children, busy with modern careers, feel extreme guilt for not having spent enough time with their mother.

In contrast to Shin’s elderly character, my wife’s grandma – in Korean, halmoni – considers herself lucky to be literate and have a school experience. Halmoni’s own schooling experience was very rare for someone of her generation. Not only can she enjoy books, her schooling experience allows her to connect with those of younger generations in ways that other members of her generation cannot. Poignantly, Halmoni’s daughters’ friends enjoyed coming over to Halmoni’s house more than being in their own homes because their own parents had no idea about their own schooling experiences. Halmoni would ask questions about school and relate to what her daughters’ friends were going through.

In Korea, having rapidly gone from a very impoverished, poorly educated society to one of the wealthiest and best educated on earth, the experiences between different generations are widely different and lead to what Koreans call the “generation gap.” While improved material living standards on the surface are a positive, the accompanying generation gap has led to social isolation for the elderly who cannot relate to their family members even if they are lucky enough to live with their families.

Further, many elderly see themselves as an economic burden on their families. With a Confucian culture of hyo-do (filial piety) that has traditionally depended on families to support their elders, social security and pensions are inadequate for much of the elderly population. South Korea’s rate of elderly poverty is extremely high, with some estimates saying it is 50 percent. Unmet cultural expectations of being taken care of by one’s family likely further contribute to elderly depression.

In her all-encompassing look at suicide, “Night Falls Fast: Understanding Suicide,” the author Kay Redfield Jamison discusses how lower serotonin levels are associated with higher rates of depression, severe mental illness, and suicide. In experiments with adult male vervet monkeys, she discusses how the monkeys “appear to show a day-to-day consistency in their blood serotonin concentrations as long as they are living in stable group environments. When there is a shift in a group’s dominance pattern, however, the transition from a lower to a higher position is accompanied by an increase in serotonin. When dominant male vervet monkeys are isolated in cages and have no visual or tactile contact with other members of their group, their serotonin concentrations drop by 50 percent. If they are returned to their original social group, their serotonin concentrations rise to their original levels.”

The generation gap can lead to obvious social isolation and thus lower serotonin levels and a higher susceptibility to suicide. Furthermore, following Confucian tradition, many elderly Koreans who expect to be on the top of the social pyramid at the end of their lives in fact end up abandoned and isolated. In addition to the decrease in serotonin that comes with social isolation, elderly Koreans are deprived of the increased serotonin they would get from moving to a higher social position within a group. Michael Breen, in his excellent new book, “The New Koreans,” states, “If Descartes had been Korean, he would have said: ‘I am in charge, therefore I am.’” Not surprisingly, the extreme isolation of elderly Koreans and their lack of movement up social hierarchies likely causes lower serotonin levels, which if untreated probably cause many suicides (more on treatment for Korean mental health in a later post).

The legacy of trauma and violent death: The Korean War Generation

Poverty, isolation, dislocation and unmet social expectations are also accompanied by the traumatic experiences of the many elderly who survived the Korean War and the accompanying destruction and separation. My wife’s grandma (halmoni), for instance, lived in North Korea prior to the Korean War where her sisters married men from further north. In middle school when the war began, her older brother was forcefully conscripted into the North Korean army. Along with her younger brother and parents, they watched as their house was destroyed in the fighting and fled as refugees. Making their way home, they found they were now citizens of South Korea as the border had shifted. She never saw her elder sisters – nor her conscripted brother – again. She assumes her conscripted brother was killed in action while she heard rumors one of her elderly sisters was killed by advancing South Korean forces due to her husband’s position in the communist party of North Korea.

In the case of Halmoni, and countless others like her who lived through the Korean War, the loss from violent death is further compounded because the actual cause of death is assumed to be violent but even that is lacking certainty. Several years ago, Halmoni, my wife, her parents, and I went to a former POW camp for North Korean soldiers in South Korea. Halmoni cried for much of the visit, saying “I just cannot stop thinking of my older brother. Did he die in a place like this? Was he killed in battle? We will never know.”

Dr. Edward Rynearson, founder of the Separation and Loss Services program at Seattle’s Virginia Mason Medical Center and author of “Retelling Violent Death.” Photo courtesy.

As grief and loss expert and psychiatrist Dr. Edward Rynearson discussed with me recently, violent death is often more traumatic than natural death for the bereaved because they lack a place in the “death narrative”. When one dies slowly of cancer, loved ones experience the death process together and as such there is more closure. In violent death, the bereaved are left with questions about how exactly the loved one passed away and what pain they experienced at the time of death.

Halmoni considers herself lucky since she did not lose her parents and still has one sibling. In addition, she did not suffer the extreme poverty that many did in South Korea during the 1950s and 1960s. Moreover, she lives with her youngest daughter and her family and is not lonely. However, so many of her generation not only live alone, but are left with traumatic memories of a divided family, a childhood cut short, recollections of extreme hunger, and unresolved cases of loved ones’ violent deaths. Additionally, according to a Korean mental health professional who works with elderly Koreans in Seattle, many elderly Korean women also feel a shame at having worked as prostitutes while younger to survive their extreme poverty. She stated that, “In general, elderly Koreans often suffer depression in part because they have extremely negative and traumatic experiences from their younger years that they have not discussed.”  Traumatic experiences in one’s younger years correlate with mental health issues and suicide later in life.

The need for social connection and community

Poverty, isolation, and traumatic life-experiences are all parts of a severe lack of social connectedness that contribute to suicidal thoughts and actions. In her page-turning novel (“Pachinko”) about the Korean diaspora, Min Jin Lee’s Korean-Japanese character Mozasu discusses how “[…] I thought it would be better if I died, but I couldn’t do it to my mother […] I can never let her down like that.”

Mozasu is the son and the connection to his mother keeps him going. Furthermore, by staying alive Mozasu could fulfill his obligations of hyo-do to his mother. Ultimately, the key to reducing elderly suicide in Korea may be the same key to reducing the suicide rate across society – social connection between the young and old and a strong, tightly-knit family where people live with or near their parents. While my friend Sok-Ki may sacrifice some of his independence to live with and care for his mother, his mother felt his dedication and he also derived both satisfaction and love from the opportunity to serve his mother. Social connectedness achieved, depression and suicide likelihood lessened.

South Korea has moved from a tightly-knit society of high social connectedness to one where individual desires take precedent over traditional duties to one’s family. All Koreans must take a hard look at their responsibility for creating strong social connectivity between all people from all age groups. South Korea’s economic growth and transformation show that while South Korea may be materially rich, the side effects of this growth have caused a deep psychological and social disruption throughout the nation that have deadly effects.

– By Chris Juergens