CW: suicide, mental illness
The lifetime prevalence of mental health disorders in South Korea is one out of every three people, slightly higher than the world average of one in four. In light of the high profile celebrity suicides in 2019, I decided that I wanted to know more about the state of mental health care in South Korea. In doing my research, I learned much more about the mental health care system in South Korea and the types of care that are available to South Korean citizens. However, there was a dearth of information regarding the care available for the non-Korean speaking, expat community in South Korea. So how do therapists in South Korea work with the multifaceted and deeply cultural mental health issues that foreigners experience here? This was the question that guided my search as someone who has dealt with anxiety since college and has peers who have experienced various forms of mental illness. I sought out Dr. Ebesutani to hear more about his experience working with the English-speaking foreigner population in South Korea.
Dr. Chad Ebesutani is a US and South Korea Licensed Psychologist and Director of the Seoul Counseling Center. The Seoul Counseling Center—with locations in both Sinsa-dong (Gangnam) and Pyeongtaek (near the Camp Humphreys US Army Base)—is a space for English-speaking expats, international students, Korean Americans, and army personnel and families to receive counseling from certified South Korean and American therapists. Dr. Ebesutani is also an Associate Professor of psychology at Duksung Women’s University, where he runs a Child Psychology Research Lab focusing on evidence-based treatments and the assessment of mental health skills usage among both clinical and non-clinical populations.
I started off our time together by asking Dr. Ebesutani about the most common mental health issues/disorders that he encounters among his foreigner clients. He stated that depression and anxiety are the most common disorders. With South Korea having the highest suicide rate of all OECD (Organization for Economic Co-operation and Development) countries, this observation was not surprising even among the foreigner population. He noted that social anxiety and panic disorder were also common problems he encountered at his center. I recalled a time when I used to suffer panic attacks in college as a result of my uncertain academic future. I would wake up in the middle of the night, heart thumping so hard that I could feel it in my ears. Social anxiety is also a condition I deal with on a day-to-day basis here even as a Korean American—so this observation was, again, not surprising to me. I wondered how foreigners, who often have left a significant part of their support systems back in their home country, work through such problems.
But there were two additional issues that Dr. Ebesutani raised that I had not expected: societal integration challenges and alcohol abuse. According to the Journal of Korean Medical Science, South Korea is home to the highest prevalence of alcohol abuse/alcohol dependence among OECD countries, with approximately 7% of the population suffering from this disorder. These two problems often strongly impacting the expat life in South Korea is noteworthy, as often in South Korean workplace culture, alcohol is the gateway to inclusion in the greater workplace ecosystem through what is known as ‘hwe-sik’ (회식), the South Korean after-work company dinner.
Dr. Ebesutani and the psychologists at his clinic work with many Korean American clients. Korean Americans in Korea belong to a unique niche of people who straddle the line between belonging and alienation. And it is not surprising that Korean Americans also deal with issues of societal integration. Dr. Ebesutani noted that lack of comfort with the Korean language was often the issue that prevented this population from feeling like they are truly “Korean.” Ultimately, this issue boils down to the issue of identity and feelings of isolation from one’s community. As a Korean American, I empathized deeply with what Dr. Ebesutani’s Korean American clients were feeling. I came to Korea hoping that by being here and integrating into the social fabric of my home country, I could feel more “Korean.” And after a year and a half of being here and working on my Korean as well as my mannerisms, I have integrated somewhat. But as a Korean American, that is not enough. Korean people asking me where I’m from, innocent comments from teachers about how well I eat the food, and the phrase “You’re so American” all contribute to the separation of Koreans and Americans.
This idea of isolation from community as a Korean American in South Korea may seem paradoxical at first. However, unlike “proper” non-Korean foreigners, Korean Americans are often met with criticisms along the lines of “You’re Korean, so why can’t you…?”. As long as you look Korean or reveal that you are part Korean, there is a certain expectation that Korean people have of you even if you have never engaged with the culture for various reasons; meanwhile, our non-Korean foreigner counterparts are given praise by local Koreans for their smallest dip into Korean culture. Our hyphenated identities often create conflicts within ourselves regarding our sense of belonging and identity as Korean people. The mental health issues that people face in South Korea, just like anywhere else in the world, are embedded in culture and require a nuanced understanding in order to address.
The South Korean government has been slowly but surely developing its response to mental illness in the past 20 years. The Mental Health Act of 1995 in South Korea and its subsequent revision in the 2016 Act on the Improvement of Mental Health and the Support for Welfare Services for Mental Patients (AMSW), are two of the most prominent government initiatives to promote the welfare of people suffering from mental illness. However, Dr. Ebesutani informed me that these Acts were created primarily to care for individuals with serious mental illnesses (SMI), such as those with schizophrenia, severe bipolar disorder and severe major depression who experience substantial impairment to their daily functioning. Several people, however, require mental health services for issues other than SMI, such as mild depression, anxiety, ADHD, panic attacks, OCD, addiction, and trauma, as well as several others emotional and behavioral problems. Dr. Ebesutani described mental health services for these types of less impaired people as being in “its relative infancy” in South Korea and “the quality of programs [that are already in place] have yet to be vetted”.
When one reads into the 2011 National Mental Health Five-Year Plan that came between the two Acts, this focus on SMI is clear. This plan focuses on five distinct aspects of mental health care in Korea: the reduction of inappropriate hospital stays, improved quality of care for hospitalized patients, increased preventative care, establish systems of care for alcohol use disorders, and reduce prejudice against those with SMIs. Only one facet focuses on the types of “invisible” disorders that Dr. Ebesutani and psychologists like himself see every day.
Dr. Ebesutani also brought up the problem of how even if we have effective mental health services for less impaired people with mental health challenges, “we still have a treatment engagement problem that we have not solved yet in the field [worldwide]”, whereby many people needing treatment do not seek them out, and those who do start treatment often drop out prematurely. A 2013 study of over 13,000 Korean people with depressive symptoms found that only 16% underwent mental health consultation. If the South Korean people’s engagement with mental health consultation is this low in a country where they speak the language and can readily seek out resources for care, what does that mean for the populations of foreigners who cannot?
I asked Dr. Ebesutani about if he thinks that the work he is doing is changing mental health care in Korea. His honest answer? “Not yet.” In his article on cognitive behavioral therapy (CBT) in Korea, Dr. Ebesutani questions the exclusion of health insurance coverage of psychologists and other professionals without a medical degree from conducting CBT in hospitals from the National Health Insurance Service. CBT is a form of psychological therapy that has been proven to work based on hundreds of scientific studies to change negative thinking patterns and in turn change maladaptive behavior patterns. This exclusionary rule relegates the provision of (insurance-covered) CBT treatment in South Korea onto Korean psychiatrists and neurologists who may or may not have ever been properly trained in CBT. Dr. Ebesutani emphasizes the importance of “increas[ing] access to treatments for patients by diversifying provision rights to various professionals”, which would entail including psychologists and mental health counselors on the list of professionals from whom people under the South Korean national health insurance plan could receive CBT for their mental health challenges. In America and other countries, it has been shown that PhD-level psychologists and masters-level therapists can provide effective CBT despite not having a medical degree. It is my hope that as more and more Korean psychologists return from studying in the US, they can bring with them this knowledge that will hopefully aid in reshaping the landscape of mental health care in South Korea.
The topics of serious mental illness and the lack of mental health professionals brought us back to the topic of that was the genesis of this whole article. The suicides of Sulli and Goo Hara, two prominent K-pop idols, in 2019 left a scar on the Korean peninsula. I asked Dr. Ebesutani about what sort of effects these two events would have on the landscape of South Korean mental health care. To my surprise, he talked about how the deaths of these young women could, unfortunately, fuel further hatred online. As each woman cited the internet bullying as a source of their mental health problems, Dr. Ebesutani believed that these deaths were demonstrations of how much power internet bullies can have on a person. Dr. Ebesutani hopes that “TV and movie producers see the value of promoting counseling and therapy in movies and TV shows”. When asked to expand on this comment, Dr. Ebesutani explained that he wishes that popular media would help normalize and encourage people to seek out help in the form of therapy. I whole-heartedly agreed with him. The power that popular media has on the trend-loving country of South Korea is something that has been demonstrated time and time again. Helping to normalize therapy in a country where stigma towards those with mental health issues acts as a barrier to care is crucial.
As our time together was nearing its conclusion, I asked Dr. Ebesutani if he had any final words for those who may be reading this article. I mentioned that a lot of my peers have and continue to suffer from those mental health problems that plague many twenty-something year-olds: anxiety towards uncertainty, feelings of loneliness, a loss of meaning and hope in one’s life, among other negative feelings and experiences.
Many people often assume that leaving Korea will solve their problems. However, Dr. Ebesutani had a somewhat different view: “[leaving Korea] may certainly solve a lot of your problems, but not the ones you need to solve”. As someone contemplating how much longer he can stay in this country, this comment indeed resonated with me quite deeply. In the end, he had these words to say to all of us trying to figure out our places in life:
“Wherever we are, it’s not a coincidence. Your choices are not random. And neither are your emotions. Do your best to keep your emotions from immobilizing you—and instead, use them as a messenger to learn more about who you are and where you need to go and what you need to do. Keep moving forward. Face your most difficult emotions and never stop growing. Become the person you need to be, and then you’ll find your way home.”
HeeJae was a Fulbright ETA from 2018-2020 in Cheongju, Chungcheongbuk-do. He graduated from Tufts University in 2016 with a BA in child study and human development and in 2018 with a MA in clinical developmental health and psychology. Currently he is working as a project coordinator on a research project headed by the professor from Duksung Women’s University interviewed in this article.