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Demography and Immigration
The Korean American population in the U.S. is 1,076,872, an increase of 1500% since 1970 (U.S.Census, 2000). New York State has the nation’s second highest population of Koreans numbering approximately 230,000 (Donnelly, 2005). The majority of the population lives in New York City (86,473) and most of those residents are in the borough of Queens.
Koreans in general and Korean children are less likely to encounter poverty than comparable population groups. However, more than 1 in 4 elderly Korean immigrants in New York City (28 percent or 1,716) live below the poverty line, surpassing the city’s overall elderly poverty rate of only 18 percent (Jang et al., 2006).
Many Korean immigrants left professional employment in Korea to move to the United States. However, due to the language barrier, they were often unable to find professional positions commensurate with their educational and occupational backgrounds. As a result, many Korean-Americans are self-employed in small, family businesses that do not require extensive English language skills (Jo & Dawson, 2010).
New York City’s Korean immigrant population capitalized on their connections in Korea, to establish strong import and wholesale businesses in the United States. In the New York – New Jersey metropolitan area in the early 1990s, there were a total of about 500 Korean owned import businesses that supplied Korean and Asian-made goods to other Korean wholesalers in NYC and throughout the country. As of 1990, there were approximately 700 fish retailers and 350 garment-making Korean-owned businesses in New York (Min, 2006).
During the second World War, the Korean Church served as a rally against Japanese occupation, creating a strong base for Christianity in Korea (Yang, 2006). Still, it is common for Koreans to incorporate several spiritual views into their religious belief system. Among the religious views embraced by Koreans are Confucianism, Shamanism, Taoism, Buddhism, and Christianity (Beller et al.). Only 25% of the population in Korea practices Christianity; while 60-70% of Koreans in the United States identify as Christian. In addition to the Church’s religious function in the U.S., it may also offer non-religious services to Korean immigrants. In many cases, the Church acts as a powerful support group, with services including income tax preparation, English education classes, health education, employment assistance, aid for the elderly, and information about U.S. citizenship (Beller et al.). Given the religious, spiritual, social, and psychological significance of the Korean immigrant church, researchers would do well to build liaisons with these churches as potential cultural consultants or as entry points to the Korean immigrant community ( Kim & Kelly, 2006).
Prevalence rates of mental illness
There are no epidemiological studies reporting rates of psychiatric illness for Koreans as an aggregate group. Asians are underrepresented in the outpatient system, but they are more likely than African Americans, Whites, and Hispanics to have psychotic disorders (Sheying, 2003). Asian Americans appear to have an increased risk for symptoms of depression and express more somatic symptoms of distress than White Americans (U.S. Department of Health and Human Services, 2001). Korean Americans have higher rates of depression than Japanese Americans, Filipino Americans, and Chinese Americans. More Korean males are diagnosed with major depression than any other group of Asian males (Kuo, 1984). It has been reported that self- treatment for depression and other mental health issues results in increasing rates of alcohol abuse in Koreans (Duranceaux et al., 2008; Helzer et al., 1990).
Anecdotally, psychiatrists working with Asian immigrant groups report that depression in Asian Americans seems to be aggravated or brought on by adjustment to life in a new country. Seventy percent of Korean American households speak Korean at home (U.S. Census, 2000). The stress of learning English or the inability to speak it can lead to anxiety or intensify an existing mental illness, particularly for immigrants who were highly educated in Korea but find themselves barely able to communicate here in the U.S.
The Korean Consulate General has reported a doubling of suicides in 2009 to a total of 15 among Korean citizens living in the United States. The Korean Times, a newspaper published in the United States, counting both Korean citizens and Korean-Americans within the New York area, reported at least 36 suicides. These rates have been attributed to the economic crisis, the Korean emphasis on achievement, and feelings of shame over failure (New York Times, Dec. 31, 2009).
Length of residence seems to influence the general mental health of Korean immigrants. In the first one to two years in the U.S., language barriers, culture shock, social isolation and difficulty in securing employment serve as stressors. With acculturation, English fluency, and advanced economic status, mental health seems to improve (Jang et al., 2007).
Cultural views of mental illness
Asian Americans view an individual’s wellness holistically, with the mind and body working in tandem (Mio & Iwamasa, 2003). Confucian philosophy discourages open display of emotions in order to maintain familial and social harmony and to avoid the exhibit of personal weakness. Consequently, the body becomes the site of the expression of psychological distress (Chun et al., 1996; Lin, 1996).
Because of their belief that psychological distress is a manifestation of an organic disorder, Koreans think of depression as a physical sickness or a lack of motivation (Kleinman & Good, 1985). Consequently, they attempt to overcome emotional difficulties with willpower and self-discipline (Kim, 2005). In fact, the Korean language has no specific word for depression; someone feeling depressed may talk about having a “down heart”. The language discrepancy may make identifying a need for treatment more difficult.
In Asian societies, alternative and folk medicine is employed as treatment for mental disorders (Marsella & White, 1982). Traditionally, the Korean view of health is rooted in the balance of Ki (“Chi” in Chinese medicine) energy, which is conceptualized as the interdependence of the person with social, supernatural and climactic conditions (Sheikh & Sheikh, 1989). The Korean folk syndromes Shin-byung (신병 ) and Hwa-byung (화병) are listed in the DSM-IV as culture-bound syndromes, and can serve as a gateway to understanding culture’s role in psychiatric morbidity (Somers, 1998). Shin-byung is a symptom of anxiety or panic episode with bodily complaints. Hwa-byung, which translates in English as “anger syndrome”, is attributed to the suppression of anger, disappointment, grudges, and unfulfilled expectations (APA, 2000).
Maintaining a balanced state is believed to be a prerequisite to health (Do, 1988). Kibun, which has no direct translation but refers to a person’s mood and feelings, must be good in order for a person to function without disorder. In interpersonal relationships, keeping kibun harmonious often takes precedence over all other considerations (Harris et al., 2004).
The Korean American Mental Health Fact Sheet (The National Alliance on Mental Health, 2007) recognizes that there are three core cultural concepts for Koreans:
• Haan (한) - Suppressed anger, unexpressed grievance, resentment
• Jeong (정) - Strong feeling of kinship/interpersonal trust, emotional bonding
• Noon-chi (눈치) - A capacity to quickly evaluate another person or social situation
Because these concepts are central to the Korean understanding of mental health, they should be respected during treatment. Cultivating jeong in the treatment process, practicing noon-chi, and acknowledging the presence of haan has been recommended as an effective way for clinicians to increase their cultural competence with Korean American clients (Kim, Kim & Kelly, 2006).
Impact of cultural values on the use of mental health services
Korean families value filial piety, clearly defined family roles, family collectivity and interdependence (even at the sake of individualism and independence), and education (Chin, 1993: Kiyano & Daniels, 1988). Traditionally, men hold higher status than women in Korea (Shin et al.). These values remain intact in immigrant families but often create discord during the acculturation process.
While Western egalitarian marriage is not embraced by Korean immigrants, a study by the Asian & Pacific Islander Institute on Domestic Violence (2005) revealed that 33% of “male-dominated relationships” experienced at least one incident of domestic violence during the year, compared to only 12% of “egalitarian” relationships. The divorce rate is three times higher among Korean American men and five times higher among Korean American women than the respective rates in Korea (Coles, 2005).
Among male immigrants, work-related factors such as occupation, income, and job satisfaction show the strongest correlation with mental well-being. Family life and socialization with other Koreans are also related, but to a lesser extent (Hurh, 1998). In a study of university students, findings indicate that Korean American men report relatively high levels of anxiety (Hovey et al., 2006). Highly educated Korean men who are unable to find professional employment may develop problems with alcohol abuse or domestic violence subsequent (NKI Focus Group Report, 2012).
In distinction from men, Hurh (1998) found that social factors such as quality of family life and socialization with other Korean women were stronger indicators of mental well-being than work-related factors. Few mental health differences were noted between female immigrants who worked and those who did not, however high individual earnings actually had a negative impact on women’s mental health (Hurh, 1998). In Korea, domestic responsibility belongs to women and fiscal responsibility belongs to men. In the U.S., economic factors often require both men and women to work outside the home, so an additional burden is placed on working married women, who are still expected to take care of housework (Hurh, 1998). Additionally, Korean men find themselves in a predicament, often suppressing their anger and resentment for the American egalitarian way of life (Min, 2001). Korean women often find employment doing menial labor, thus becoming the primary breadwinners, while their husbands are forced to stay at home. This may result in uncomfortable family dynamics and frequent discord (NKI Focus Group Report, 2012).
Korean American adolescents appear to experience more mental health problems than other ethnic groups (Greenberger & Chen, 1996). Perception of low maternal warmth as well as conflicts due to acculturation have been correlated with depressive symptoms in Korean American adolescents (Kim & Cain, 2008). Korean immigrant parents are guided by traditional Asian values, such as collectivism, conformity, self-restraint, and silence, while their children tend to adopt such American values as individualism, autonomy, assertiveness, and self-expression. This often leads to conflict within the family (Lee, 2004). Language may also serve as a source of conflict, with the adolescent learning and becoming fluent in English, while the parents continue to speak Korean.
Historically, education has been the primary catalyst for young adults to excel socially in Korea. Scholastic achievement is highly revered while other venues of achievement are ignored or devalued. This orientation toward academic achievement creates unwarranted demands for success and, in turn, overwrought perfectionism in the Korean American adolescents (Kim, 2005).
When conflict is not dealt with, Korean American children tend to exhibit more depressive symptoms and lower self-esteem than counterparts (Park, 2003). Research suggests that a successful family intervention focused on promoting parental warmth and alleviating intergenerational acculturation conflicts could be successful for alleviating depressive symptoms in adolescents (Kim & Cain, 2008).
Elderly Korean immigrants typically do not seek professional help or prescription medication for depressive symptoms, and tend to rely more on cognitive, religious, physical, social, and/or artistic strategies to treat themselves (Pang, 1996). Higher levels of acculturative stress and less social support are associated with higher depression scores in the elderly (Han et al., 2007). Conversely, those who report good relationships with their adult children and good physical health show lower rates of depression (Jang et al., 2006).
The cultural practice of providing care to the elderly remains strong in Korean American immigrants. It seems apparent that some burden is placed on the adult children of mentally ill elderly Koreans and that this burden poses as a risk factor for the mental health of the caretaker (Yuen, 2002).
Mental health service utilization challenges
Korean immigrants attach great stigma to mental illness (Leong & Lau, 2001). In a culture that encourages suppression of individual emotions for the sake of the collective community, admitting to or recognizing symptoms of mental illness comes at a high cost (Jang et al, 2007). The Korean American community considers family to be one large unit. Thus having a family member who is different from expected norms can be a great source of distress and shame for many Korean families, and traditionally, such members have been hidden away from public view (Mi-Yeong Jo, Book article). It is important to assure patients of confidentiality and anonymity, to address shame and stigma, and to help them verbalize these feelings. Moreover, it is useful to reframe help-seeking as consonant with maintaining the family’s good name (Kim, 1988).
Additionally, the strong Christian-belief system in Korean Americans seems to influence understanding of mental illness as a symbol of inherent evil (Kim-Goh, 1993). Moreover, it is reported that some Korean clergy advise their clients with mental illness not to comply with treatment and medications. These clergy discourage help-seeking behaviors; recommend alternative treatments, such as fasting or praying; and perform exorcisms. It would not be unusual for many Korean American families to turn first to traditional Eastern medicine, such as acupuncture or homeopathic care, to deal with everyday medical or mental health issues. Physicians and mental health workers should ask Korean American clients, especially those older or less acculturated, about use of Eastern medicine and views on the effectiveness of such treatments, since this information may provide some insight into willingness to accept Western-style practices and recommendations (Jo & Dawson, 2010).
Korean Americans with emotional disturbance turn to mental health services as a last resort, preferring to seek assistance from family and friends, informal social networks, and community organizations (Akutsu et al., 2007). Education seems to have a positive influence, as immigrants with higher levels of education are more positive than those with less education about seeking professional mental health services (Yi & Tidwell, 2005).
Language serves as a barrier to treatment in a number of ways. Oftentimes, Korean immigrants are unaware of the services available to them. They may also drop out of treatment if language proves to be a problem (Donnelly, 2005). Other culture-bound communication rules seem to prevent Korean Americans from utilizing treatment. It is considered highly disrespectful for Koreans to make eye contact; this is especially true between people of different genders, ages, and/or social status. Meaningful conversation is highly regarded, while small talk is seen as pointless; in Korea, value is placed on silence. Smiling and joking are acceptable only under certain conditions, and are otherwise viewed as disrespectful (Beller et al.). These cultural distinctions make talking with a clinician about feelings highly uncomfortable.
Economic problems also serve as a barrier to healthcare. One out of every four elderly Korean immigrants lives below the poverty line, making access to health insurance and mental health services nearly impossible for this demographic (Jang et al., 2006).
Impact of acculturation on treatment
Korean Americans face the challenge of integrating their Korean and American cultures (Kim & Choi, 1994). There are three methods of dealing with this challenge: creating a balance between both cultures (integration), exclusively following either Korean (separation) or American culture (assimilation), or following neither culture (marginalization) (Berry, 1997). In a study of Korean women, immigrants who scored low on both American and Korean acculturation had higher levels of depression than those who scored higher on American acculturation, Korean acculturation, or both (Choi et al., 2007).
The common problems associated with acculturative stress are perceived discrimination, cultural incompatibilities, and intergenerational conflicts. Symptoms of acculturative stress include anxiety, depression, hypersensitivity, heightened psychosomatic symptoms, and in worse cases, suicidal ideation (Berry & Annis, 1974).
Western philosophies and ideals have been integrated into Korean American life, but fundamental Korean morals and values remain intact. In their efforts to facilitate positive outcomes, mental health professionals have a responsibility to seek information and knowledge about the persons they intend to help. A familiar Korean proverb speaks directly to clinicians aiming to help Korean immigrants:
아는 길도 물어가라
"Even if you know the way, ask one more time."
[Nancy Sung Shelton, Dana Matsushita, Rachel Levenson, and Jin Woong Yoon contributed to this report.]
© 2008, OMH
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