Korea's struggle with institutionalized mental healthcare

Posters are displayed at Samgakji Station during disability protests in August. / Courtesy of Jack Greenberg

By Jack Greenberg

Solidarity Against Disability Discrimination (SADD) resumed demonstrations aboard Seoul subways on Nov. 7 during the rush hour commute. The protests followed a brief suspension during the national mourning period for Itaewon disaster victims. Despite criticism for heightening the risk of safety accidents and overcrowding, the activists see no other option to make their voices heard. Their demands, which include increased budget allotments for disability needs and tangible support for deinstitutionalization, have continued to fallen on deaf ears.

Apart from the protests, Korea's deinstitutionalization movement received a boost in October when the U.N. Committee on the Rights of Persons with Disabilities concluded the state's periodic review and issued its first-ever guidelines on deinstitutionalization. In its observations, the committee noted with concern Korea's weak implementation of its deinstitutionalization strategy, particularly for persons with psychosocial disabilities, as well as a persisting lack of budgetary and other measures to facilitate patients' living arrangements in the community. Per the CRPD, institutionalization is a discriminatory practice and a "form of violence" that denies individuals their legal capacity to live independently in society.

Like in other countries, the Korean government's favored solution for dealing with mental health patients has historically been isolation from the community. During the 1910-45 Japanese occupation, Korea was unique among the empire's colonies: no mainland laws regulating the custody and care of the mentally disabled were ever passed. Police, however, engaged in the surveillance of those suffering from psychosocial disorders. They maintained lists of people prohibited from wandering alone because of their symptoms and sent those without guardians to the Government-General Hospital in Seoul. Under the Minor Offences Act of 1912, police could arrest family members who failed to confine 'dangerous' mental patients at home.

Mental illness was the target of intense social stigma and a subject of public fear in colonial Korea, in ways not too different from today. As Theodore Yoo emphasizes in his study, "It's Madness: The Politics of Mental Health in Colonial Korea," media discourse contributed to the criminalization of mental illness through sensationalism. Newspapers also influenced public opinion in favor of isolation and segregation by calling for the enactment of strict custody laws and construction of large asylums.

The 1950-53 Korean War ravaged the country's medical infrastructure, and the health system's capacity to function. Mental patients were discharged, and left vagrant unless they had family members willing to take them in. The Seoul City Mental Hospital in Cheongnyangni, which opened in 1945, was the sole psychiatric institution that remained operational throughout the war, albeit barely.

The 2018-closed Cheongnyangni Mental Hospital, once known as the Seoul City Mental Hospital, was originally founded in 1945 and rebuilt in 1966. / Courtesy of Jack Greenberg

Capacity to care for those needing any form of health treatment remained extremely limited as the nation emerged from the shadows of war. Only 1 percent of the national budget was allotted to the health ministry, three-fifths of which went to programs for veterans and Hansen's disease patients. Although hard data was not collected, numerous reports pegged the number of people with severe mental illness at roughly 100,000. In 1957, however, there were no more than 359 inpatient psychiatric beds throughout the nation, the majority of which were at a veteran's relief hospital in Seoul's Noryangjin neighborhood.

At the end of December 1961, the National Mental Hospital was inaugurated with 360 new inpatient beds, 140 less than originally planned due to funding difficulties. The patients included overflow veterans and young, jobless men with limited education, who were involuntarily admitted at the request of a spouse or relative. Long-term hospitalization was de jure policy. As the hospital's superintendent explained in a 1962 article for the journal Neuropsychiatry, patients could not "expect early discharge… [since] there is no system [that] provides aftercare or psychiatric social services." Underfunding and insufficient staffing would continue to plague the National Mental Hospital for decades to follow. As the country's only mental health institution serving the needy free of charge, it had a months-long waitlist. In the 1970s, it was also forced to limit inpatient treatment to periods of no more than three months, yet many patients had to be readmitted shortly after discharge.

Inmates at Seongjiwon in Daehwa-dong, Daejeon, an accommodation facility for individuals rounded up under anti-vagrant ordinances / Korea Times file

With the public system struggling to find the money to stay afloat and meet demand, private actors, both legitimate and illegitimate, stepped in to offer their services. Richer families sought private psychiatric assistance while the poor opted to lock patients in their homes or dropped them off at unlicensed 'prayer houses,' often located on the mountainous outskirts of major cities. Rather than receiving actual treatment in such facilities, patients were routinely tied up with ropes or chains and violently beaten, sometimes to death, during rituals aimed at exorcising their inner "demons." Meanwhile, from 1975 through to the end of the Chun Doo-hwan regime in 1988, patients on the streets were rounded up and delivered to private-run social welfare facilities under an extraconstitutional anti-vagrant ordinance. Certain facilities supported these patients in a true spirit of service, yet abuse, violence and death were widespread due to failures in regulations and monitoring.

Human rights grievances involving patients with psychosocial disabilities did not disappear with democratization. In 1995, the Mental Health Act was passed after a 27-year on-off effort, but problematic provisions remain, despite countless amendments. Involuntary institutionalization is still possible on the grounds of patients' perceived dangerousness to themselves and others and continues to be abused with improper admissions and discharges. The adult guardianship system also limits the active decision-making capacity of individuals based on psychosocial impairment.

Reductionist demands for deinstitutionalization will not be realized soon. There are indications that institutionalization is still preferred by a sizeable number of patients and their families, who fear the burden of care will be shifted to them without adequate supports in place. Moreover, discrimination and stigma remain deeply entrenched in society. Substantive progress depends on educating the public about disability rights, developing capacity-building programs for lawmakers working on disability-related policies and adequate investments in financial and social service resources to incrementally build up a system of independent living transition and community integration services, without which the human rights of people with mental disorders will remain in a precarious state and at risk of harm.

Jack Greenberg is a Global Korea Scholar at Korea University, pursuing a master's degree in International Studies. He wrote a dissertation at McGill University on the history of mental health in Korea, and will give a lecture titled, "Locked Up: Korea's Struggle with Institutionalized Mental Health Care" for Royal Asiatic Society Korea at the (historic) Korea Christian Building on Nov. 22. at 7:30 p.m. Visit raskb.com for more information.