<![CDATA[How a deadly US epidemic is fuelled by Korean mental health taboo]>
Beneath her was a pool of blood. She was 16 and assumed it was menstrual blood, so she decided to go to the bathroom to change " but when she attempted to get to her feet, she fell back to the floor.
Her head was throbbing. She called out to her parents. No one came. She called out to her younger brother, but he did not respond either. Finally, she crawled to her parents' bedroom. Her father's leg hung over the bed. She shook it to try and wake him. When he did not respond, she crawled to a radio and turned it on at full volume to get someone's attention. Eventually, she dragged herself to the bathroom and used the ledge of the tub to hoist herself up, only to fall back down and lose consciousness. When she came to, she found herself on a stretcher on the way to a hospital.
"I didn't know what was going on," Binna said, recalling the night's events. "I tried to make them call my parents to come and pick me up. But obviously they knew something that I didn't."
The paramedics would tell her only that she had been shot at her home in Echo Park, Los Angeles.
That week, there were three family murder-suicides in Southern California's Korean-American community. On April 2, a 54-year-old local business owner locked himself and his two young children in his SUV and set it on fire in downtown Los Angeles. His T-shirt manufacturing business had failed and his wife had filed for divorce.
On April 8, a 40-year-old man shot and killed his five-year-old daughter and himself in his home in Fontana after months of unemployment and the accumulation of US$200,000 in gambling debt.
That was also the day Binna Kim was shot. Her father, Sang In, a 55-year-old property agent, also shot her mother and her eight-year-old brother and himself. With a bullet lodged behind her ear for 30 hours, Binna was the only survivor.
For six months, Binna did not really understand what had happened to her or her family. Whether it was the daze of the hospital medication or simply the chaos of it all, she did not even remember if she asked where they were. It was only when two detectives came to speak to her that she was told her case had been classified as a murder-suicide.
"What do you mean, a murder-suicide?" she remembers asking. "That means that it was someone in my family who did this to me."
Young people seen in Koreatown in October 2006, Los Angeles. Photo: Getty Images/AFP alt=Young people seen in Koreatown in October 2006, Los Angeles. Photo: Getty Images/AFP
According to Jae Kim (no relation of Binna's), a licensed clinical social worker at the Los Angeles County Department of Mental Health, even though that week in April was a particularly morbid time for the Korean-American community, suicides " and even murder-suicides " are not anomalies.
Koreans die by suicide at a staggeringly high rate in the United States, said Jae, who has almost 10 years of experience organising suicide-prevention programmes for California's Korean-American community. Immigrant Koreans account for around 90 per cent of ethnic Korean suicides.
As a 2018 article in the Seoul-based publication 10 Magazine put it: "Arguably, the added stress that Korean-born immigrants face as they try to adjust to life in the US is less applicable to those who were born in the US and are therefore more familiar with the local culture."
It is difficult to quantify these trends in the US. State and federal data tend to be separated by race rather than ethnicity. Issues like poverty, lower education and suicide rates that are prevalent in the smaller subgroups (Korean, Puerto Rican, Vietnamese) of larger categories (Asian-American, Hispanic) often go unnoticed.
One of the few organisations that collect suicide data by ethnicity is the Centres for Disease Control and Prevention. Its annual mortality reports show that ethnic Koreans in the US die by suicide at disproportionately high levels " while suicide accounts for only 1.6 per cent of Caucasian deaths (32,275 out of 1,971,663), for Koreans the figure is 4.4 per cent (165 out of 3,740).
There is no single explanation for this. The reasons probably overlap and coincide with the factors that contribute to the suicide crisis in South Korea, which has the second-highest rate among highly developed nations.
Since 2000, the number there has more than doubled, and is now more than twice the average for member states of the Organisation for Economic Cooperation and Development. Experts cite various cultural and economic factors: extreme pressures to succeed, cultural stigmas about mental health treatment, high rates of alcoholism, social isolation and an unreliable welfare system.
An illustration of Dangun Wanggeom, founder of the first kingdom of Korea, with the tiger and bear of Korean legend. Photo: Facebook alt=An illustration of Dangun Wanggeom, founder of the first kingdom of Korea, with the tiger and bear of Korean legend. Photo: Facebook
According to Korean mythology, a bear and a tiger prayed to Hwan-ung " the son of the Lord of Heaven and the creator of the City of God on Earth " to be transformed into humans. Hwan-ung told them to remain in a dark cave for 100 days, eating only garlic and mugwort.
The challenge was difficult; the tiger quickly gave up and returned to the wild. The bear suffered silently throughout the ordeal and persevered, and was transformed into a woman. She subsequently bore a child with Hwan-ung who they named Dangun Wanggeom. The latter founded the first kingdom of Korea and ruled for a century and a half.
The bear-woman myth loomed large in the Korean-American psyche, said Jae, the social worker. The virtues of self-abnegation, of suffering in silence, seem indelible, ingrained in many Koreans and Korean-Americans alike.
No Korean who grew up, as I did, listening to the founding-myth story, wants to be the tiger, the one who was granted the opportunity to become something better and squandered it because of weakness and lack of grit. We were brought up to be the bear, the creature who lives in darkness, clinging to the promise that silent suffering will be rewarded.
Young Korean mothers suffering post-partum depression are often sternly discouraged from talking about their struggles. Any mention of hardship elicits a nonchalant response: "It's difficult for everybody." Family breadwinners, who in Korea are often the father and husband, are seen as social failures at any mention of financial hardship.
During my high school years there, some of my classmates began to stress-vomit from the intensity of our studies, yet not a single parent told them to take some time off. I am confident they were told, "It's tough now, but just hold on a little longer" " just as I was. Again and again, the message seemed to be: "Everyone is struggling. You're not the only one, so suck it up."
When I first approached this topic, it made little sense to me that Koreans in the US, who in theory should be free of the pressures of Korean society, are still three times more likely than other Americans to die from suicide " and the number is rising.
Like many immigrants, Koreans brought with them the hope that their immediate sacrifice would result in something better in the future: an American education, financial success, social mobility.
"I think a lot of social pressures actually come from within the family," said Charles Armstrong, who formerly taught Korean Studies at Columbia University.
"So, if the expectations within the family remain and communities here maintain similar values of success as back in Korea, then it would make sense that the responses to those expectations in the US would be the same as back in Korea."
Armstrong suspects that the intense societal pressures Koreans put on themselves become amplified as they adjust to the new cultural environment in the US " an adjustment often marked by intense isolation and the absence of a social network, especially among older immigrants.
"You have a fairly large number of people who come to this country as older adults," he said. "And this kind of extended family system tends to break down after a while."
Older immigrants often get left behind by their children, who do not want to bear the responsibility of caring for their ageing parents, as was traditionally expected in South Korea. Korean widows, who on average outlive their husbands by six years, are at a particularly high risk for suicide.
"Providing a community and network for the elderly is a difficult challenge," Armstrong said. He recalled how an acquaintance's mother attempted suicide, after having moved to the US with her son and his family. She believed she was a burden to the family and a source of friction between her son and daughter-in-law.
She quietly lay on her bed, prepared to end it all. "It was very private, behind closed doors, within the family. I think that's a fairly typical approach, particularly among the elderly. She probably would have succeeded if her family hadn't stopped her in time."
Older Korean immigrants often struggle with loneliness. File photo: AFP alt=Older Korean immigrants often struggle with loneliness. File photo: AFP
Sang In Kim, Binna's father, immigrated to Los Angeles in 1990. For several years, he ran a motel, and then he went into real estate.
Binna remembers him as a reserved man who showed his affection to his children through gifts but rarely through verbal or physical means. Even when her family was struggling financially, her father continued to buy her small gifts and often took the family out to eat, never hinting at the reality of their situation.
I met Binna at a small bakery-cafe in Greenwich Village, New York; she had come to her favourite city to visit friends. It had been more than a decade since the shootings, and she recounted the day to me in an almost rehearsed fashion " doubtless honed by the years of retelling it to psychologists, close friends, reporters, and audiences at suicide-awareness events.
"It's not OK for us to talk about our feelings," she said, cupping her hands over her coffee. "The older generation especially, I think, is not used to talking about their emotions, and my parents were like that, too. I don't even know how to talk about my emotions, and I think that makes us more vulnerable to things like this."
Binna has undergone years of counselling mandated by the State of California. She was reluctant at first, and did not believe it would really accomplish anything, but she became thankful for the role it has played in her life as she moved on, began college, started on her new job.
"For the first few weeks of therapy, I didn't talk. All I did was cry," she said. Her therapist persisted and, eventually, Binna started opening up to her, realising she could use therapy as a tool to help herself.
The first time she felt thankful for her therapist was when she had her school photos taken soon after the incident. "When those pictures came back, I realised how deformed my face was, because of the incident," she recalled. "I called my therapist right away and I think that's the first time I felt, 'This is why I need this'."
Mental health services are more readily available in the US than in South Korea. But Dr Yoon Im Kane, a Korean-American psychologist who practises in New York, notes that the first-generation Korean clients she sees tend to have a huge ambivalence towards seeking them out, even more so than their Korean-American counterparts born in the US or other Asian clients. Many immigrants would not even consider it as an option.
"They worry about being labelled crazy or disabled, or ending up at an insane asylum," Kane said. "For most New Yorkers, it's more accepted that you have a psychologist that you talk to and relieve stress. There's no understanding of that in the Korean culture."
Dr Christine Joo, a mental health specialist catering to Korean victims of domestic violence in New York, sees similar dynamics in her practice.
"I think it's fair to say that in traditional Korean homes, even if someone is experiencing bouts of sadness and anxiety, those are not things they can talk to parents or family about," she said. "Koreans often don't understand that depression and anxiety are never the person's fault. It's an illness, not something that can be controlled. There are appropriate treatments."
An emphasis on "getting on with it", which unavoidably stigmatises mental illness, is perhaps one of the most potent legacies of the bear and tiger myth. A deep shame associated with what is perceived as weakness not only prevents people from seeking mental health services, but also hinders those who have lost loved ones to suicide from receiving closure.
Some of this may be chalked up to systemic challenges. About half the Koreans living in New York have limited English proficiency, and a quarter do not have health insurance, according to a 2017 report by the Asian-American Foundation.
But social stigmas play the largest role. A 2017 mental health report released by the Asian-American Federation revealed a "yawning gap between the Asian community's high depression rates and low service-utilisation rates".
"The way to deliver mental health services isn't to plop a therapist down in a community group," said Howard Shih, director of research and policy at the Asian-American Federation.
"You have to create all of these feeder programmes and other ways of getting people to start accepting the concept of mental health care, preventive care, to get them to think of therapists as a primary care kind of model rather than going to mental health services when things are at their worst."
Female protesters shout slogans during a rally against spy-cam pornography in central Seoul in August last year. The target of their fury: so-called molka videos which largely involve men secretly filming women in schools, offices, trains, toilets and changing rooms and which are so prevalent they make headlines on a daily basis. Photo: AFP alt=Female protesters shout slogans during a rally against spy-cam pornography in central Seoul in August last year. The target of their fury: so-called molka videos which largely involve men secretly filming women in schools, offices, trains, toilets and changing rooms and which are so prevalent they make headlines on a daily basis. Photo: AFP
In the US, and in most places around the world, men die by suicide much more frequently than women. Women account for around 22 per cent of total suicides in the US, but Korean women make up around 38 per cent of all suicides in their ethnic group " roughly in line with the gender breakdown in South Korea, which has the highest rates of female suicides in the developed world, according to data released by the OECD.
Kane, the psychologist, said the high rates among Korean women might be linked to the country's long history of institutional misogyny. She recounted that when her mother was born, her great-grandmother left her lying on her face so she might suffocate " for the mere reason that she was a girl.
"I'm 43 and my mother, she's one generation back. That's not that long ago," Kane said. "There's an underlying culture that sees a lack of value in women, and I can't imagine that on some level you don't internalise that.
"You feel worthless because you are female, and I would imagine that that would make it easy for women to kill themselves, because they don't feel entitled to a valued life."
South Korea also has an extremely high rate of domestic violence. According to a 2017 study of 2,000 Korean men, commissioned by the Korean Institute of Criminology, almost 80 per cent of respondents said they had either physically or psychologically abused a girlfriend while dating her; a separate survey released by the Korea Women's Hotline revealed that 61.6 per cent of female respondents admitted to experiencing abuse in relationships.
That culture seems to have been carried over into the Korean-American community, according to the Korean-American Family Service Centre, a non-profit organisation that helps Korean victims of domestic violence in New York.
By the organisation's estimates, the numbers in Korea are quite similar to those within the community here. According to a 2000 report by The National Institute of Justice and the Centres for Disease Control and Prevention, as many as 60 per cent of married Korean women in the US say they have been physically assaulted by their husbands.
Unsurprisingly, domestic violence survivors, who tend to be women, face a greater risk of suicide. Women who have experienced intimate physical violence are seven times more likely to report current suicidal ideation than their counterparts who have not, according to various studies.
As with any kind of abusive situation, the reasons for staying with a partner are complicated, but for immigrants unfamiliar with the laws and cultures and language of their new country, situations often become more dire before the authorities and organisations can help.
"Just talking to our local precinct's domestic violence unit, they tell us that even compared to other Asian groups in our community, Koreans and Korean-Americans are the ones who wait until the last minute, until it gets so severe that they have to report," said Saenam Kim, deputy director of the Korean-American Family Service Centre.
"They also say a lot of times it's not even they themselves who are reporting, it's their neighbours or people on the street, because Koreans and Korean-Americans are not willing to do that themselves, even if it's affecting their lives significantly."
Gender inequality was one of the causes of violence against women, the World Health Organisation stated in a 2017 global report, and South Korea " which places 116 out of 144 countries in gender equality " is no exception.
Social pressures there were extremely severe, said Jisu Lee, a 25-year-old writer based in Seoul. "You're expected to walk the expected path " a good education, a well-paying job, a suitable partner of your calibre, health and happy children " in order to be considered normal." Taking a step outside that path becomes an invitation for intense judgment.
"As Korea developed quickly," she said, referring to the economic boom in South Korea in the late 20th century, "I think there was a dismissal or ignorance of individual struggle or pain. People think to themselves, 'Even if it's difficult for me, it's fine as long as my family can be happy. If I hold on for a little longer, this group can keep on rolling forward'."
Ultimately, Jisu thinks the high suicide rates among female Koreans in the US and in South Korea have to do with the double whammy of sexism and existing pressures.
"If you mess up once in Korean society, that's the end of your life," she continued. "For those around my age, if you can't get a job at a decent place, then it's just the end of it all. You'll spend your entire life earning 2,000,000 won (US$1,650) a month, and then you'll get old and hurt and then fired. Your life will be over.
"And for women it's even more difficult. If you're 26 and aren't on the right path yet, people will say your life is just over already."
In The Vegetarian, an acclaimed novel by South Korean writer Han Kang, the protagonist, Yeong-hye, one day suddenly renounces meat, saying she has chosen to do so because she "had a dream". For months, she exists in a dazed state, barely talking, becoming more and more reclusive and disturbed.
When readers are allowed glimpses into Yeong-hye's mind, we witness rare moments of clarity, but more often we see incoherent streams of consciousness that depict violence and mental anguish: "Animal eyes gleaming wild, presence of blood, unearthed skull, again those eyes," Han writes. "Rising up from the pit of my stomach. Shuddering awake, my hands, need to see my hands. Breathe. My fingernails still soft, my teeth still gentle."
Those around Yeong-hye can plainly witness her mental unravelling, yet not a single person " even those who seem to genuinely care about her " encourages her to seek treatment.
Instead, at the climax of the story, Yeong-hye is force-fed a piece of meat by her father, who becomes enraged at his daughter's decision to become a vegetarian. He forces her mouth open as he says: "If she eats it once, she'll eat it again. It's preposterous, everyone eats meat!"
Yeong-hye wrestles away from her father's grip and picks up a fruit knife from the dining table. She doesn't attack her father. As her family watches, she slits her wrists. After the incident, as Yeong-hye slips into a further state of mental decline, her family commits her to an asylum and all but denies her existence.
Koreatown in New York City. Photo: Shutterstock alt=Koreatown in New York City. Photo: Shutterstock
After Binna recovered, she moved in with her family's pastor for a short period, and then with her best friend; their mothers had been best friends as well and because their families were close and had grown up together. "It was kind of natural," she said.
She graduated from high school in 2008 and went on to Loyola Marymount University, from which she earned a degree in communications in 2012. The day her father shot her was the day before Binna was supposed to leave for New York with friends to do a campus tour of New York University, and catch the musical Chicago.
Years later, Binna found her chance to finally move to the city when she was accepted into the Miami Ad School in Queens. She now lives in Washington, working as a copy editor for an advertising agency, though she said New York would forever be her favourite city and that she wanted to come back one day.
At the cafe, Binna and I talked about how she felt about the incident now, looking back at it years later. We talked about what a shame it was that mental illness was so stigmatised in our community. She told me about her tattoos and her reluctance to date because of her physical disability.
She talked about the culture shock she felt at her predominantly white college and we laughed about her love for Sex and the City and her subsequent love for New York because of that show.
She told me that two of her friends' parents had also killed themselves in the years following her own family's death, and I told her about my aunt, who had taken her life when I was a child and whom I had forgotten about because her name had never come up in family discussions since.
Then, near the end of our conversation, I asked Binna something I had been wondering since we had first talked on the phone months before. Was she happy?
She paused. Then she said: "I feel like I know what I'm doing with my life and my career. So yes and no. But no one can be completely happy, right?"
Topics such as suicide are rarely talked about within the Korean community, and Korean survivors of suicide are also often unwilling to talk about their experiences. Photo: AFP alt=Topics such as suicide are rarely talked about within the Korean community, and Korean survivors of suicide are also often unwilling to talk about their experiences. Photo: AFP
In the US, there are efforts under way to separate data by ethnicity, a process called data disaggregation. That could raise awareness of issues confronting smaller ethnic groups. But, so far, few state legislatures have passed bills that would actually implement the practice.
Disaggregating data would be expensive. "There are a lot of archaic computer systems that the government relies on, and it becomes really expensive to add additional categories," said Howard Shih of the Asian-American Federation.
"So that's the rationale, the resistance from the state and local agencies. In reality that's a technical problem that you can fix. But it takes a commitment of funds " it's a budget problem, not so much a policy problem."
There are also fierce opponents to data disaggregation, largely from more widely represented groups within the Asian-American community.
They argue that disaggregating would disadvantage their communities in matters like college admissions, since policies like affirmative action would begin to give the upper hand to minority Asian groups which had previously been less represented in higher education.
Andrew Gelman, a professor of statistics and political science at Columbia University, said when he first started analysing survey data in the 1980s, information was even more aggregated.
"We would just look at whites and non-whites, and that was because for everybody else, the population was so small that anything you saw would be too noisy to report," he said. "And so now we'll say whites, blacks, Hispanics, and others, because there's a lot more Hispanics and others than there used to be."
But because the sample size for other groups was so small, he said, it was hard to learn much from it.
If state and federal surveys, with the data they collect, are trying to determine what kind of people " from a pure numbers perspective " are at the most risk for suicide, the answer of course is white males, because whites make up the largest portion of the US population and because men kill themselves at far higher rates than women.
If the goal is to decrease the overall number of suicides in the US, it makes sense to target this group. Minority communities, even with disproportionately higher rates, are not a priority.
It certainly does not help that topics like suicide are rarely talked about within the Korean community, and Korean survivors of suicide are also often unwilling to talk about their experiences. A few years ago, a support group for suicide survivors sprang up in Orange County, but it was quickly disbanded because so few people showed up at meetings.
"That situation just goes to show how difficult talking about suicide is within the Korean-American community," said Jae from the Los Angeles County Department of Mental Health.
Pointing to suicides within the Korean-American church that he attends in Los Angeles, Jae said in every instance, the surviving families chose to leave the congregation " because, he speculates, of the shame they felt.
"One family just left to go back to Korea, and others decided to move [to other] churches," he said. "Even during funerals, the pastors are deeply uncomfortable, because they find it so difficult to talk about suicide."
Koreatown in central Los Angeles, California. Photo: Shutterstock alt=Koreatown in central Los Angeles, California. Photo: Shutterstock
As a Korean woman and as an immigrant, I find it impossible not to view all these statistics, these stories, in the context of family members and friends I have lost or feared losing to suicide, against the backdrop of those around me who have lost their loved ones.
There is no easy solution, no simple answer, to remedy the problem, and most definitely no way to bring back the people who are no longer here.
In the course of reporting this account, I kept coming back to the founding myth that has been a part of me since childhood, the lesson of the bear and the tiger.
But for me, on reflection, the lesson has changed. Knowing what I know now, I cannot help but sympathise with the tiger, the one who escaped from the cave and was permitted to roam the wild as it pleased. I bet, at the very least, it felt free.
Throughout most of my conversation with Binna, she never lost her composure. It was only when I asked her if she often thought about her family that I saw her cry " but only for a moment. "I think about them every day," she said.
"My parents were deep in debt. From the letter my father left behind, it sounded like he was only going to take his own life and my mum's, but obviously it didn't go that way. I think he was just afraid that if he left us, we would have to clean up his mess, and I think that's why he tried to take all of us with him.
"For some reason, I've never had any anger towards him, or resentment," Binna said. "Which is really weird, and I can't explain it myself."
But she went on: "I know why he did it, and I understand why he did it."
If you, or someone you know, are having suicidal thoughts, help is available. For Hong Kong, dial +852 2896 0000 for The Samaritans or +852 2382 0000 for Suicide Prevention Services. In the US, call The National Suicide Prevention Lifeline on +1 800 273 8255. For a list of other nations' helplines, see this page.
This article originally appeared on the South China Morning Post (SCMP).
Copyright (c) 2019. South China Morning Post Publishers Ltd. All rights reserved.
