What Is It to Be Mentally Healthy from the North Korean Refugees' Perspective?: Qualitative Research on the Changes in Mental Health Awareness among the North Korean Refugees.

OBJECTIVE: We investigated how mental health awareness among North Korean refugees transformed depending on temporal-spatial context changes.
METHODS: In 2013, we conducted interviews with 10 refugees (eight women) who had been in South Korea for over a year and performed a qualitative analysis of the change in mental health awareness in the differences between living in North Korea, escape (a related period of forced sojourn in a third country), and settlement in South Korea.
RESULTS: We classified 39 concepts into five main categories. The first two categories (while living in North Korea) were "a mindset for the system, but not for individual mental health" and "being confined in a social environment that was indifferent to mental health." A third category appeared during escape: "focusing on survival amid continuity of intense suffering." The final two categories appeared when settling in South Korea: "recognition of mental health amid cultural shock" and "introspection and sorting oneself out."
CONCLUSION: This qualitative study enabled a better multi-dimensional understanding of the social and cultural aspects involved in improving mental health awareness among North Korean refugees in South Korea. It is desirable to integrate mental health as a part of daily life and to expand training for North Korean settlers.

INTRODUCTION

It has been almost seventy years since the Korean War (1950) occurred and for the Korea peninsula to be separated into South and North. While South Korea progressed rapidly in terms of their market economy and political democratization, North Korean economy under the successive dictatorship and shut-down political regime regressed. After the years of ‘Arduous March’ with continuous flooding and drought, North Korea became the poorest country in the world, not being able to guarantee the security of its own people. ‘Arduous March’ was a form of party slogan proposed by Kim Jung-Il after the death of Kim Il-Sung to overcome the nationwide economic difficulty and to prevent social disintegration by forcing its people to sacrifice for the nation [1]. During those years, the number of people suffered from the lack of food and health services in the malfunctioning social system [2]. As a result, not only did the number of people dying from hunger grew dramatically but also the number of survivors crossing the borderline to South Korea grew as well. According to the recent announcement made by the Ministry of Unification, the total number of North Korean refugees in South Korea sums up over 30,000 [3].

Political and economic system holds a great power in determining the national identity and in changing the people’s values and perspectives [4]. North and South Korea each having been exposed to different regime and system, is considered two different entities. This concept can be applied exactly in the same manner to the ‘people’ as well. Both North and South Koreans received different education, economic activities, social and cultural experiences so far. We expect such difference to appear also in the area of mental health. As the recognition of mental illness is highly influenced by the sociocultural factors, we may assume for a big difference between North and South Koreans’ perception on this issue [5].

Mental health is defined as a “state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community” according to WHO [6]. Keyes (2007) explains ‘subjective well-being’ as individuals’ evaluations and judgment of their own emotional status, psychological and social functioning [7]. Higher the subjective well-being of an individual, more lively the life will become. On contrary, if one’s subjective well-being is low, the life will be inactive and painful. Park [8] describes mental disorder as the state of having: 1) Self-perceived pain, 2) Pathological diagnosis, and 3) Disability in social and professional capability. Conversely, mental health is not a painful state but a positive state such as being joyful or satisfied with no official diagnosis. In other words, it is a state where an individual can perform a social activity without difficulty [8]. There has long been a strong prejudice and stigmatization for those with psychiatric issues especially in South Korea [8,9]. In order to alleviate such tension, South Korea renamed the Department of ‘psychiatry’ into Department of ‘mental health’ in August 2011. North Korea is a country with the strong sense of socialism and paternalism and one of the primary function for the existence of patriarchal society in North Korea is to maintain their regime [10]. North Korea has been utilizing their people’s emotional state for the political purpose which is to maintain the regime, to strengthen the national identity and to fight against the external powers [11]. However, after experiencing the ‘Arduous March’, North Korea faced the most difficult time in their history. North Koreans who have been protected by the government, were suddenly abandoned, managing the extreme hunger and breakup of families solely on their own. This historical event turned out to give a ‘collective trauma’ [12] or ‘cultural trauma’ [13] among the North Korean population. Negative perception on the mental health issues makes the patient and their family demotivated to seek for treatment and rehabilitation [14]. Unfortunately, North Koreans who are used to respect the regime’s supremacy more than themselves, have a tendency to hide their mental health issues [15].

Referring to previous research concerning attitudes on mental health and mental health patients, negative attitudes about mental illness hamper the treatment process. Looking at the research amongst healthy members of society, the overall attitude towards persons with mental health issues is positive [16-18]; however, attitudes turn negative when people’s lives are directly affected [17]. Research among North Korean refugees on their awareness of consultations and consulting institutions shows that 30% of respondents knew about available specialist consultations and the treatment process “a little” or “very well” and 70% “do not” or “know only very little.” Awareness of a psychiatrists’ role was highest amongst respondent from teenagers to those aged in their 30 s, with those aged in their 40 s, 50 s, and 60 s scored relatively low: 13%, 33.3%, 20%, respectively. On the other hand, awareness of doctors’ and psychologists’ role increased with the length of time the refugees spent in the South. The longer the period of settlement in the South, higher the North Korean refugees’ became aware of mental health [19-21]. Therefore, understanding how much the North Korean refugees know about the ‘mental health’ or ‘mental illnesses’ and how they perceive such concepts will be an important task for them to fit well in the South Korean society.

Until now, many of our studies focused on the pathological aspects of North Korea refugees’ mental health issues (ex. prevalence of mental illness) rather than understanding it in a contextual and sociocultural way. According to many refugee studies, it is important to understand how splitting out the ‘pre-settlement’ and ‘post-settlement’ experience may be one of the psychological causes for post-traumatic stress disorder [22].

This study tries to explore the sociocultural background of mental health issues among the North Korean refugees and its possible intervention by qualitatively analyzing the changes in mental health awareness. Our study examines how their mental health awareness changes across time and places, moving from North Korea to the 3rd country and to South Korea. Understanding how they perceive mental health issues with their distinctive sociocultural perspectives would facilitate the process of finding out an appropriate intervention for them. This study would not only help the current North Korean refugees living in South Korea but also to prepare ourselves for the future of united Korea.

Methods

Research plan: qualitative analysis

This study qualitatively analyzed the changes in mental health awareness among North Korean refugees residing in South Korea through in-depth interview. Due to the fact that researchers wanted to explore both the objective facts and subjective experiences of the participants, this study was done in a qualitative format. Moreover, it is necessary to examine the study of this kind more so to provide a basis for other studies. There exist several sub-methodologies in qualitative studies such as phenomenology, grounded theory, ethnography, narratives, case study etc [23]. In this study, we have chosen to explore the phenomenon with diverse approaches rather than the traditional approach which selects 1 primary method for the analysis.

Data analysis

North Korean refugees have been living a life with given information and support from the shut-down regime of North Korea. Even though they are currently living in South Korea, what they have gone through during the ‘North Korean Famine’, its fear, survival and trauma still remain inside. For them, escaping from North Korea must have been the most important event and must have influenced their social interaction with others. Taking such into account, we aimed to analyze the sociocultural context of ‘changes in mental health awareness among North Korean refugees’ based on the flow of the time and the changes in places/countries as to ‘From North Korea-’, ‘During the escaping process-’, ‘In South Korea-’.

Words taken out from the transcribed data was first sorted out by time and location, tied into a separate concept unit and formulated into a sentence. These sentences went through the process of categorization for the final result.

Sample and setting

Participants in this study were recruited from North Korean defectors in Seoul and Gyeonggi prefecture region Hana Centre. They agreed to interviews after hearing an explanation of the project. A purposive sampling method led to 10 participants being selected for their experience, using mental health services, working at medical institutions, knowing about the mental healthcare system in the North, or having a general interest in mental health. To improve study reliability, interviews were conducted by a researcher with over 10 years’ experience counseling North Korean refugees.

The research participants comprised 10 North Korean refugees (eight women) who had been in the South for longer than a year. Their average age was 46. One years with one person in their 20 s, two in their 30 s, three in their 40 s, three in their 50 s, and one in their 60 s. The average time spent in another country as part of their escape was 26 months. Eight participants had families in the South with them; two were here alone. In terms of residence, six participants lived in Seoul and four lived in Gyeonggi Province. Six participants were employed; four were unemployed. Information on participants in the in-depth research interviews is listed in the Table 1.

Table 1.

Basic information about the interviewees

Participant	Sex	Age (years)	Sojourn in other countries during escape	Entry date to South Korea	Family in South Korea?	Place of residence	Occupation	Eligible for national basic living allowance
Participant 1	F	36	2 yrs 2 mths	March 2008	Yes	Seoul	Unemployed	Yes
Participant 2	F	55	1 mth	July 2010	Yes	Seoul	Doctor	No
Participant 3	F	37	2 yr 4 mths	March 2010	No	Gyeonggi Province	Unemployed	Yes
Participant 4	F	45	2 mths	April 2012	Yes	Seoul	Unemployed	Yes
Participant 5	F	44	2 yrs 7 mths	November 2010	No	Seoul	Office clerk	No
Participant 6	M	58	3 mths	August 2003	Yes	Seoul	Self-employed	No
Participant 7	F	41	5 yrs 7 mths	February 2009	Yes	Gyeonggi Province	Office clerk	No
Participant 8	M	55	2 mths	April 2011	Yes	Gyeonggi Province	Office clerk	No
Participant 9	F	25	10 mths	February 2011	Yes	Gyeonggi Province	Nurse	No
Participant 10	F	65	2 mths	December 2009	Yes	Seoul	Unemployed	Yes

The in-depth interviews were held between July 1 and August 15, 2013. Each interview lasted approximately 2 hours; if interviewees agreed, they were conducted once or twice each. In the interviews, the researchers explained the research goals and content, possible discomfort, benefits of participating, how to withdraw, measures to protect privacy, and so on. Interviews were conducted after the researcher obtained the interviewees’ written informed consent. Materials were collected in an open, semi-structured way so that interviewees could participate freely. They were asked about mental health awareness and change in that awareness during life in the North, their escape, and after landing in the South. The study was approved by the institutional review board of Inje University Seoul Paik Hospital (IIT-2013-287).

Ensuring accuracy in qualitative research

We considered four criteria: truth value, applicability, consistency, and neutrality, which were proposed by Guba and Lincoln [24] to ensure the qualitative validity of our study.

In terms of truth value, researchers immediately produced the transcript after an in-depth interview and reconfirmed any ambiguous points by contacting the interviewee. In addition, to increase truth value during analysis, data were categorized into units of meaning and assigned academic terms. Then these terms were back-translated into units of meaning and read multiple times to ensure that the participants’ experiences had been recorded correctly. Analyses were checked for accurate recording of research participants’ experiences by two persons. To ensure applicability, results of any analyses were crosschecked for accurate content with another North Korean refugee who understood the healthcare situation in the North. To ensure consistency, a specialist with a doctorate in education was consulted to review the results via qualitative research methods.

Finally, to avoid bias or prejudice, the researcher began this study without any intention to support a certain hypothesis and remained faithful to the revealed data to ensure neutrality.

Results

The answers to the research questions for this study were analyzed in five main categories, 13 sub-categories, and 39 concepts (Table 2).

Table 2.

The change in mental health awareness among North Korean refugees

Category (N=5)	Subcategory (N=13)	Concepts (N=39)
1. In North Korea: A mindset for the system exists; however, there is an absence of individual mental health awareness	1) Difficult to identify any awareness of mental health	1	Never thought about or heard of the concept of mental health
		2	Did not know depression or insomnia were illnesses
		3	Many people die not knowing that symptoms of poor mental health are an illness
		4	Anyone not admitted to a mental health hospital is healthy
	2) Persons useful for upholding the regime are mentally strong	5	Persons of thoroughly revolutionary spirit
		6	Persons respected for their tenacity and high ethical standards
	3) Persons displaying antisocial behavior and illness symptoms are mentally unwell	7	Behavior not displayed by ordinary people (e.g., violence, theft, robbery, perverse sexual acts, alcohol, drugs, etc.)
		8	Crazy people sufferer from epilepsy and schizophrenia symptoms such as hallucinations
2. In North Korea: Confined in a country with an environment lacking interest in mental health	4) Weakening mental health due to factors specific to North Korean society	9	Infringement of privacy by party officials in group-oriented life
		10	Accustomed to concentrate on the issue of survival in a closed society
		11	Experience depersonalization due to a food shortage in North Korea’s famine period
	5) General social disregard for those with mental issues	12	Stereotype that one must isolate, criticize, and keep away from mental patients
		13	Used to not caring rather than sympathizing with others
	6) Poor environment for mental health treatment	14	The public lacks access to mental health facilities and treatment information
		15	A place called ‘Ward 49’ was meant to be for those mentally ill to await for their death
		16	Even the patients in hospitals are abandoned and starved to death
		17	There is no real place to receive counseling or psychological support
3. During the escape period: Focusing on survival amid intense suffering	7) Inability to care about mental health due to focusing on survival	18	Cannot spare time to think about mental health during escape
		19	Never heard of “mental health” nor its treatment methods
	8) Psychological pain experienced during escape	20	Feel fear, terror of being caught and remorse over having betrayed the group
		21	Difficulties due to cultural differences experienced while fleeing
	9) Expanding area for mental health, change to accommodating attitude	22	Realization that depression and anxiety should not be ignored
		23	Consider treatment possible if it is started early
		24	Beginning to consider mental health sufferers’ rights
	10) A mentally healthy person has complete social and psychological functioning	25	An individual who carries out its social and family roles well
		26	An individual with good relationships with others in society
		27	An individual who can overcome depression and stress
5. In South Korea: Introspection and sorting oneself out	11) Finally recognizing the wounded inner self	28	Feeling at a loss and ostracized from society over personal differences with South Koreans
		29	Realizing one is suffering from depression stemming from life in the North
		30	Suffering doubts over identity due to fewer social relationships than was had in the North
		31	Worry that North Korean refugees are not healthy
	12) Efforts to protect mental health	32	Collecting information on mental health and preparing countermeasures
		33	In search of the best way to deal with stress
		34	Making efforts to know oneself
	13) Difficulties treating mental issues	35	Realization of low mental health awareness
		36	Not aware of one’s own mental health
		37	Negative perception that counseling is part of North Korean state central interrogation bureau investigations
		38	Reluctance to make use of counseling services due to finances
		39	Difficulty in expressing mental health issues due to differences in language and sentiment

In North Korea: a mindset for the system exists; however, there is an absence of individual mental health awareness

Difficult to identify any awareness of mental health

Whilst in North Korea, none of the study participants had overheard of or used the term “mental health,” nor had they ever been asked about what being “mentally healthy” entailed. In North Korea, if someone does not show pathological symptoms they are not considered a threat to social safety. Participants mentioned people sometimes died as they did not realize that they were struggling with mental illness and they did not receive treatment. One who studied medicine and worked as a pediatrician in the North considered a person with mental issues who was not hospitalized. This shows how North Koreans have low awareness of mental health.

The expression “a mentally healthy person” itself just does not even exist. Does it mean something like “that person has a strong mind, a healthy mind, or they are mature.” Because this expression is different in the North, it needs to be explained; there is not even a word for mental health … (Participant 5).

When people’s thoughts start to rush in their minds, or they become weaker because they cannot sleep, then their body grows weak and it happens: the first symptom is night waking and hallucinating, sweating, and early signs of schizophrenia. Then it develops into hysteria; however, there are so many people in North Korea who have this. Therefore, they suffer and die. If there is no medication, they die, just like that (Participant 5).

In North Korea, if you have a mental issue, you are taught that it is absolutely considered a full-blown psychotic illness. Generally, everyone who is not in a mental hospital is healthy. That is how it is seen by society (Participant 3).

Persons useful for upholding the regime are mentally strong

In the North, they do not use the term “mental health.” Expressions used to describe a mentally healthy person include being able to see things from an ideological point, an ethical perspective, and a pathological viewpoint. In North Korea, the term “mindset” was often used about an anti-Japanese revolutionary spirit. A person of sound mind was someone who expressed strong will, morals, ethical prowess, and maturity. Stating that a mentally healthy person has a decisive revolutionary mindset and ethical maturity is a North Korean social phenomenon that was developed to instill communist moral education and maintain the communist system.

A mentally healthy person in North Korea is someone who is faithful to Kim Il Sung and Kim Jong Il. Someone who is forever and ever faithful to them is a mentally healthy person. Statements such as “let us brace ourselves thoroughly for our comrade the great leader Kim Il Sung’s revolutionary spirit” are said by someone who is focused and considered mentally healthy (Participant 8).

The word “mental health” is not used. We say, “that person is indeed fine” or is “well-rounded.” This is what is considered an ethical sacrifice for others. A good person is one who does not put themselves as the center of attention. This type of person in North Korea is seen as a fine citizen who is respected. There are certain rules that must be maintained for the sake of the group; someone who does not fit the ethical standard has a strange mind (Participant 5).

Persons displaying antisocial behavior and illness symptoms are mentally unwell

In the North, anyone with symptoms of sickness that develop into violent behavior endangering society is acting contrary to the reputation of the system and is considered to have a sick mind.

He had a problem with his mind. If you have a weak mind, you start drinking and become an alcoholic or your mind goes awry and you beat your wife and that sort of strange behavior happens (Participant 4).

Someone with epilepsy and people with schizophrenia symptoms and hallucinations are people who have gone crazy. These people we call mentally ill and abnormal people. It does not seem appropriate for them (Participant 1).

In North Korea: confined in a country with an environment lacking interest in mental health

Weakening mental health due to factors specific to North Korean society

In North Korea, there are no professional counselors. Government party officials manage people’s lives through the saeng-hwal-chong-hwa (life assemblies) (regular meeting for criticizing oneself and others openly), which play the role of counselor to resolve grievances. The more one expresses their personal life, the more they are recognized as being loyal; however, consultations with party officials have morphed into a means to ensure one’s political life. Many North Koreans suffer gravely because during the severe famine in the North they were forced to deviate from learned acceptable behavior and commit anti-social behavior to survive. Therefore, in other’s eyes, they cannot be considered normal. This led to wide scale sickness.

There are no psychologists in North Korea; therefore, party officials are charged with organizing the group. They control people’s mindset. A doctor treats a patient; however, party officials are “handymen” who treat the human mind. This is how it was done from the 1950 s to the 1970 s. Then, from the late 1970 s on, people began to turn to money and sexual desire. Consequently, people began to demand bribes and payments. Therefore, in the 1980 s and by the mid-1990 s, the counselor role had vanished. Somehow, everything changed and it became a society of bribes and sexual favors (Participant 6).

In North Korea, we are indoctrinated from birth. It is firmly believed that everything is the fault of the South and the United States; therefore, the focus is on how one can somehow survive poverty and struggles. One must learn whom to cheat and how, how to secure a meal, and what to do for work. It is a desperate struggle to get me that one meal and to be satisfied (Participant 3).

Due to food scarcity, there is crime in North Korea. Everyone is hungry; therefore, there is stealing from other people’s houses and even eating children. There are mental and psychological causes for looting; however, there are also social ones. To distinguish between these is very difficult; however, either way, a lot of looting took place (Participant 6).

General social disregard for those with mental issues

In North Korea, there is a need to control the media because if someone suffering from mental illness makes politically dangerous remarks it could be a problem for the authorities and the system. Therefore, persons with mental disorders are labeled useless to the system and are confined in isolation at a mental hospital (e.g., Ward 49). Rather than providing treatment and valuing patients’ individual dignity and life, mentally ill people are segregated from society to preserve social order. It is easy to see how indifferent and cynical the social atmosphere is.

Psychiatric patients are not allowed to wander around outside by themselves. Mental patients lack self-control and say whatever they wish. It is a serious issue when something like this undermines the authority of the party leadership (Participant 2).

When I think about it now I do not know why they did not send her to Ward 49. Perhaps because they loved their daughter so much. Around 1995, she was hit by a military vehicle and died. Well, it was good that she died. After all she was a psychopath; however, that was not ever a serious issue (Participant 5).

Poor environment for mental health treatment

Psychiatric hospitals called “Ward No. 49” in North Korea are mostly located in rural areas. The intention is to emphasize the superiority of the socialist system by isolating and treating patients in areas of natural beauty far away from the general population. No access is granted and no information about treatment is available to the public. In addition, the wards are perceived as terrible prisons where people are in lockdown and tortured to death. If admitted, there is no other recourse to receive counseling or treatment. After the famine, rationing stopped and the health system collapsed; therefore, it was difficult to maintain even general hospitals. Consequently, it was more difficult to operate the mental hospitals and provide treatment there.

The North stands for socialism. Nothing is allowed in or out. Therefore, it is difficult to see these kinds of patients (Participant 2).

There is not a need for the public to even be aware Ward 49. They do not know even if they exist or not (Participant 5).

As far as I know, it is almost certain death when you go there. Almost everyone thinks that is the case. If you do not do as you are told, they beat and torture you. It is Scary. They lock you in your room; however, I have only heard that. They say if you go there you never come back. If you are sent there then even your family has given up on you (Participant 9).

There are people there they call doctors; however, if they do not treat people in secret and sell medication out the back door they are unable to make a living. In my opinion, there is no way that people being treated at the psychiatric wards are being fed properly (Participant 3).

If you go in there you will probably see many people die. I say that because of the child beggars, who Kim Jong-Il once ordered to be taken away. He said that having them “wandering about” reflected a poor national image. Food such as steamed corn does not supply enough nutrition; therefore, any children who are weak or malnourished may die there right away. Perhaps the neurological wards are somewhat like that. People lose their minds and just disappear. If they are not seen for a few years, people think they probably ended up dead somewhere. That is what people conclude (Participant 7).

Unless I am admitted to a psychiatric hospital, there is no way I could go and receive counseling and treatment. If I were really struggling with depression and felt terrible, there would be nowhere I could go for support. There are no counselors (Participant 4).

During the escape period: focusing on survival amid intense suffering

Inability to care about mental health due to focus on survival

When asked about changes in mental health awareness while fleeing the North, most participants never heard of or thought about it. During their dangerous escape while risking their lives, defectors considered personal safety and survival to be the most important. Similar to living in the North, people could not afford to think about mental health when fleeing.

Thinking about mental health will not keep you alive. That is what people do when they have time on their hands (Participant 5).

I only learned that mental health problems could be treated with medication when I was in South Korea. I did not know anything about this when I was in China. In the North, they are completely unaware of this (Participant 1).

I began to study mental health and psychology and learn about myself when I came to South Korea. In the South, it is much safer and the conditions are much better; however, I do not know why I am thinking about these things. I had these thoughts for the first time after I came to South Korea. In North Korea, I only had the odd thought. While in China, I did not think about this at all (Participant 5).

Psychological pain experienced during escape

In North Korea, deciding to escape itself is an unhealthy idea. It is a criminal act that amounts to betraying the motherland. Defectors are in a protracted state of constant fear of being caught and sent back to the North and being punished. Therefore, most defectors suffer psychological distress during defection. When in situations of life and death and constantly under extreme stress, people tend to develop serious mistrust. These psychological effects have negative effects after entering and settling in the South as people lack trust in other Koreans and the government.

They all have mental issues due to the traumatic stress felt on their way over here. Those that were caught and repatriated suffered harsh and terrible things. They must have suffered much pain for risking their lives to come here. Moreover, if they had children or parents in the North, the separation itself must have caused pain (Participant 2).

There was a woman, a doctor, who went into a complete panic. She became strange. In the South, when examining her own child, she used a stethoscope on top of the child’s clothes. She used it incorrectly and thought it was correct. She built an incorrect preconception in her mind. She was very stand-offish towards other doctors and did not cooperate. Her w child died. That is what happens because of what people went through while fleeing the North (Participant 6).

In South Korea: recognition of mental health amid culture shock

Expanding area for mental health, change to accommodating attitude

Most of the refugees who settle in South Korea state that they receive information about mental health services offered from the local community and TV programs. Unlike what they know from the North, which describes people who act immorally as mentally ill, they find that the standard for mental health is psychological stability and they realize that even people who are capable of normal everyday life can be in need of treatment. Participants stated that by learning how to treat psychiatric patients with a variety of options they learned to consider people’s dignity and rights. Overall, acceptance of the mentally ill grew as understanding of mental health improved.

We only realized that insomnia is also rooted in poor mental health after arriving here. We had never heard that someone could have mental health issues and not go completely crazy. We found that out only after we got here. Probably, in the North, if your daughter died and you could not sleep and began to overeat they would say it was normal and not think you were suffering a mental issue (Participant 9).

I do not think it is serious. A person just has some psychological pain and treatment will help them get well again (Participant 7).

Because I had lost all functions of being human, I thought my future role in society or at home was over. I had lots of thoughts like these. After arriving in South Korea, what changed my perception was that I realized that I could be treated, and that they had various ways of going about it. Because different treatments were possible, healthy people were not discriminating against ill people. It is inhumane to discriminate against people who just happen to have caught a disease in their lives. I learned to think about human life again (Participant 2).

A mentally healthy person has complete social and psychological functioning

Refugees stated that in the South, a healthy person was not someone who existed for the system and the country, but was someone who could form well-rounded relationships in their private family and social life. Furthermore, a person with a healthy mind was seen as someone who strives and overcomes any mental trauma that might have been caused by suffering while fleeing from North Korea.

Both the North and South consider a mentally healthy person someone who performs their role in society and the family properly and takes care of their health. Someone who is physically healthy is also mentally healthy (Participant 2).

They are good at dealing with people in society and are not self-centered. When a problem arises, they work towards an agreement. For example, they do not jump up and begin a fight; rather, they explain what has happened to them and ask, “What do you think?” They offer suggestions first (Participant 5).

If they are depressed or have some worries, they can find a way to deal with it when they are health (Participant 3).

In South Korea: introspection and sorting oneself out

Finally recognizing the wounded inner self

Refugees who had been ensnared in a fierce battle for survival, felt that in South Korean the economic and socio-cultural standards and consideration for others would be higher than they were in the North. They reported a shrinking feeling whenever the differences between them and Southerners appeared in social interactions and stated that this became an inferiority complex. Because depression is not recognized as an illness in the North, people thought melancholy was a personality trait. However, after arriving in the South, and being educated on mental health, some realized they had been suffering from depression. Refugees also became dispirited and suffered from loneliness in the South because they had fewer social contacts than they did in the North. They were concerned they might be ousted because of their North Korean accent, and they were hurt because they could not fully adapt to South Korean society. Refugees felt insecure about their mental health and because of culture shock and the psychological trauma experienced during the famine and escape from the North they struggled to adapt to life in the South.

It is probably a cultural difference, but that is where I could see their true character. For example, we would make plans to see a movie together. Then, just as I am about to leave, I would send a text message saying I could not make it today for whatever reason. Then, I would get a text back saying, “You have to keep the appointments you make first.” The reaction was like it is unusual to have to cancel. Why make this such a big thing? Then I realized, I saw their true character. However, at the same time, I also felt inferior (Participant 5).

In the North, they do not think depression is a psychiatric illness. I think I was a little bit like that since I was a child. I married my husband and I think that is probably why I am like this today. In pictures, I am a bit “expressionless.” I can see it now; however, I did not know it then. I had depression even back then but no one thought it was a disease. People would say, “That kid is quiet” or “She has some worries,” not that I had a psychiatric illness. I did not know of such a thing (Participant 1).

My whole family is in South Korea; however, when you walk down the street in the North, you see many of your friends and people you know. Here, there is nobody, and when you call someone on the phone, they ask if you are a Chinese ethnic Korean or from North Korea. When that happens, it is like mental blow (Participant 8).

I wonder if all North Korean escapees should receive some treatment. We suffer many shocking things on our way here; many psychological things happen to us. They say because we did not live in a stable environment that we struggle psychologically (Participant 1).

I know I am not yet mentally healthy; however, I want to fix it. In the future, I must work; however, that is not possible in my current mental state. There are too many psychopathic symptoms going on inside of me. There is too much volatility and severe mood swings. Managing my emotions is difficult (Participant 5).

Efforts to protect mental health

North Korean refugees acquire knowledge about mental health through mass media. Unlike in North Korea, where there is no concept of menopause, women make efforts to prepare for possible menopausal depression. They can also find ways to relieve the stress that they learn about. Counseling leads to self-analysis and self-reflection. People learn to take a positive stance towards wanting to treat their own psychological problems.

When the depression comes, I want to have counseling. Because I hear there is an illness you get when you reach your 50 s. On TV, it said that when depression appears the family must support you a lot (Participant 7).

I am not sure if this is boasting; however, because I have overcome all that pain, I know that whatever suffering I am faced with I can deal with. Either by studying books or watching TV, I have found my own way to solve my issues (Participant 2).

If only someone would give me some advice on what to do about certain things. Is it called psychological counseling? It would be great to receive counseling. I have tried a lot of referrals. I would like to receive some counseling. I received some at a church once (Participant 5).

Difficulties treating mental issues

North Korean refugees learn about mental health from community service agencies and the mass media. Therefore, it takes a certain time to adjust to life in South Korea before one can realize and acknowledge the need for mental health. Despite needing psychiatric care and having suffered severe emotional trauma in the North, treatment is delayed as refugees do not yet have awareness of mental health and fail to recognize that they have a problem. Counseling in North Korea is reminiscent of government interrogations. In the South, counseling at the Hanawon (North Korean migrant settlement support facility in South Korea) or Hana Centre is thought of negatively because it is viewed as an extension of Northern practices. The Korea Hana Foundation was implemented at the Hana Centre with professional counselors; however, the participation rate is low. There is a desire to receive professional counseling from private organizations rather than from government agencies because refugees fear their private information could be leaked. However, in many cases, access to civilian counseling is limited due to costs and restraints on medical insurance. In addition, due to the long period of separation and socio-cultural differences, defectors struggle to adequately express their feelings to South Korean doctors and counselors. They think that the people sitting across from them will not understand them; therefore, they are quite passive when it comes to counseling.

I do not know about counseling, mental health education, health, or how to get treatment whatsoever. We have never been in Korea; therefore, how could we know? One way to develop myself is via mental health; we do not know about that concept, and if we do, awareness is very low (Participant 5).

She said she saw her husband and her mother having sex. I thought she should really undergo psychotherapy. She probably needed it most. In life, there are so many people to argue and fight with such as refugees and your friends. If people see just a small thing that is wrong, they are a time bomb. They explode. People like that should get treated. However, people do not like to admit they are sick; that is the problem (Participant 5).

Right after we left Hana Won, there was a place called Hana Centre. It is not a mental health facility; it is a place where they interview and investigate you. It is up and running now; however, the perception of the counselors is bad (Participant 5).

In North Korea, medical care is free. Regardless of care quality, you can go anytime. However, when I see the patients in South Korea, is it called insurance? Depending on whether the insurance covers it or not, if you do not have the money, you cannot go to the hospital even if you want to (Participant 2).

The reason they do not get treatment after arriving here is that they are afraid of having to approach a hospital. Because the division has been for more than 60 years, the medical environment and language have developed differently. When people go to a clinic, the doctor cannot understand their symptom descriptions. I cannot say with confidence that I could express myself properly to South Korean doctors (Participant 2).

DISCUSSION

North Korean defectors escaped the North and came to South Korea to avoid threats to their personal safety. They faced the formidable challenge of having to adapt to an alien capitalist market economy. Various factors such as changes in this new environment, personal ties severed due to moving, lack of a social support network, and adapting to economic factors cause mental health problems. Refugees did not have a concept of mental health whilst living in the North and clinical patients isolated on Ward 49 were often mentioned. Our finding showed that North Korean refugees had high awareness level in mental disorder but low awareness in mental health. This is similar with the result of Ahn’s25 study where North Korean refugees had high awareness level in mental illness and alcohol addiction but had low understanding in depression, when compared with South Koreans. However, after entering South Korea, refugees learned to use terms related to mental health in Hanawon or where they settled. Their psychological demands grew and their grasp of the mental health expanded. Further, mental health support was reported as being needed to relieve the stresses of cultural adaptation, improve interpersonal relationships, etc., However, mental health support accessibility, education, and awareness among refugees are still lacking. To increase awareness of mental health among North Korean refugees, this study proposes the following:

First, it is necessary to educate refugees that mental health is enmeshed in everyday life. The concept and scope of mental health in South Korea and North Korea differ. While mental health in North Korea focuses on the mentally ill and clinical pathology, South Korea needs to educate its citizens that people can receive mental health services for everyday life issues such as stress, depression, anxiety, insomnia, and interpersonal difficulties.

Second, refugees need to be educated on the differences in mental health service and treatment agencies in the North and South. To deconstruct cultural prejudices about mental healthcare institutions, they need information on a variety of mental health service agencies in South Korea including how to use them, the user range, the successful treatment rate, and the treatment methods and materials used to increase accessibility and acceptance by North Korean refugees.

Third, workshops should be provided addressing the somatic symptoms (e.g., psychogenic somatic symptoms or somatization symptoms) described by North Korean refugees. It is common for refugees to describe somatic symptoms to general physicians when they enter Hanawon. They typically complain of suffering from headaches, abdominal pain, chest pain, and insomnia, and they repeatedly receive treatment for these ailments. In this case, refugees need to receive guidance on somatic symptoms in a consultation where a general physician (or family doctor) and a mental health professional are present concurrently. Moreover, repeatedly visiting a general practitioner without adequately addressing psychiatric treatment needs for somatization only hinders their efforts in settling in the South and uses up valuable time and material resources.

Finally, training workshops should be held for Hanawon and organizations supporting North Korean refugees that educate others about the differences in mental health awareness. Refugees require education on the stresses of settling in the South that are so widely described so that these issues can get recognized as early as possible.

As well as mental health training for North Korean refugees mentioned above, in parallel there should be training for counselors and medical professionals so they too understand the differences between North and South Korean mental health awareness. Therefore, they can provide approachable contact points more effectively. It is thus necessary to create a manual targeting mental health service agencies, health professionals, and everyone involved that can be used to teach basic awareness of mental health, thus reducing the existing gap in mental health awareness between North and South Korea. In other words, to increase refugees’ level of mental health awareness, not only the recipients of treatment, but also all stakeholders that support them need to raise their levels of understanding.

Therefore, it is imperative that proper information be made available to raise mental health awareness by training medical institutions about differences in language used to express symptoms, socio-cultural understanding of North and South Korea, and specific psychological characteristics. This way, North Korean refugees who are describing physical symptoms that are caused by mental health issues will not be denied necessary treatment.

Limitations

This study is significant in that it analyzed how mental health awareness among North Korean refugees’ changes depending on the temporal-spatial context and proposed ways to improve the socio-cultural understanding of their mental health. However, participants who had a specific education level and period of residence in Gyeonggi Province and the capital region participated in this research.