The International Journal of Psychosocial Rehabilitation
Improving Psychological Outcomes for North Korean Refugees:
A Research Agenda

Benjamin Eric Taylor
Department of Psychology, Macquarie University

Taylor B.E. (2017)     Improving Psychological Outcomes for North Korean Refugees:
A Research Agenda.  
International Journal of Psychosocial Rehabilitation. Vol 21 (1)  5-9

North Korean refugees often experience persistent mental health concerns after departing from North Korea. These concerns may arise in relation to traumas experienced within North Korea, bereavement over separation from family members, and difficulties in adjusting to life outside North Korea. Post-traumatic stress disorder is common among North Korean refugees, yet there is a surprising lack of research investigating post-traumatic growth among this population. Post-traumatic growth involves global changes to one’s outlook on life, and is associated with reduced psychological symptom burden among trauma survivors. Post-traumatic growth is an important component of recovery following trauma, and leads to better long term outcomes. There is a scarcity of research however investigating this phenomenon among North Korean refugees. In this short communication, a research agenda emphasising post-traumatic growth among North Korean refugees is emphasised. Areas for future research include the relationship between post-traumatic growth and autonomy, psychological grit and hardiness, and experiential avoidance. Rather than adopting a symptom-driven agenda, researchers should investigate adaptive functioning and the process of finding meaning among North Korean refugees.

The North Korean leadership has been condemned in recent times for gross human rights violations. These violations include but are not limited to, arbitrary arrests and detention, torture and forced starvation, suppression of freedom of speech, and forced labour (Amnesty International, 2015). In response to difficulties experienced within North Korea, many citizens seek to escape from the country each year, seeking refuge in neighbouring countries such as China and South Korea. Due to the extremely dangerous nature of the escape journey, the excessively harsh living conditions within North Korea, and the potential danger imposed upon family members who are left behind, many North Korean refugees experience mental health concerns such as post-traumatic stress, depression, and anxiety (Jeon, et al., 2005; Jeon et al., 2009; Kim et al., 2011).

Mental health concerns among North Korean refugees may also arise in response to difficulties in adjusting to the markedly different lifestyles and cultures that refugees experience outside of North Korea (Um, Chi, Kim, Palinkas, & Kim, 2015). To date, researchers have identified various socio-cultural and demographic factors associated with better mental health outcomes for North Korean refugees, including employment, social support, and income (Park, Cho, & Yoon, 2009; Jeon, Eom, & Min, 2013); and factors associated with poorer outcomes, including discrimination, greater transit time in China, and psychological co-morbidity (Yu & Jeon, 2008; Kim et al., 2011). Mental health concerns such as depression and anxiety may increase however with the number of years settled within South Korea (Yu & Jeon, 2008). Further, North Korean refugees are vulnerable to mental health concerns not limited to depression and anxiety, including paranoia, alcoholism, and reduced health-related quality of life (Jeon et al., 2009; Kim et al., 2011. Thus there is a need to stimulate further research on mental health concerns among North Korean refugees, with the aim of improving clinical outcomes for this population. 

Post-Traumatic Growth and Autonomy
Given that post-traumatic stress disorder (PTSD) is common among North Korean refugees, the scarcity of research on post-traumatic growth among this population is surprising. Broadly defined, post-traumatic growth refers to a positive transformative process whereby the individual experiences global changes in their conception of self, worldview, and outlook on life (Joseph, Murphy, & Regel, 2012). Post-traumatic growth is believed to occur in relation to the individuals’ struggle with their perceived ability to cope, rather than with the traumatic memory itself (Tedeschi & Calhoun, 2004). Further, individuals who have achieved post-traumatic growth are able to successfully co-exist with their distress, rather than seeking to eliminate it (Tedeschi & Calhoun, 2004).

Researchers have identified that the relationship between PTSD and post-traumatic growth among Tibetan refugees is mediated by cognitive and emotional regulating factors, including positive refocusing, putting into perspective, and refocusing on planning (Hussain & Bhushan, 2011). Post-traumatic growth has also been negatively associated with reduced social support, unemployment, and poor social integration among refugees residing in Norway (Teodorescu, Siqveland, Heir, Hauff, & Wentzel-Larsen, Lien, 2012).

The psychosocially complex situation encountered by North Koreans re-settling in South Korea is underpinned by a pervasive sense of newfound autonomy. North Koreans have come from a society regulated by the Juche ideology; which emphasises, group-based strivings, strict conformity to dictates imposed by the Korean Workers Party, and constant exposure to political propaganda (Lee, 2003). Many North Koreans have no say in key aspects of their life such as employment, place of residency, and the right to a motor vehicle (Lankov, 2014). Thus the highly progressive, individualized nature of South Korean society is markedly different to the ways of life within North Korea. Given that post-traumatic growth is enhanced by social support and a sense of belonging (Joseph et al., 2012), it is important to investigate the extent to which a newfound sense of autonomy among North Korean refugees, and the experience of a contrast between life in the two Koreas enhances or impedes post-traumatic growth. While evidence suggests that North Korean refugees do indeed experience adjustment difficulties upon arrival (Kim et al., 2011), and years after arriving in South Korea (Yu & Jeon, 2008; Um et al., 2015), there is no research exploring specific attitudes and experiences of autonomy, and how these relate to post-traumatic growth. This research may be important in informing psychosocial interventions that aim to enhance post-traumatic growth among North Korean refugees. 

Psychological Grit and Hardness
 Research has increased our understanding of how certain personality factors and thinking styles are associated with better mental health outcomes and socio-cultural functioning for individuals experiencing psychological trauma. Psychological grit refers to an individual’s tendency to persevere through adversity in order to achieve long-term goals (Duckworth, Peterson, Matthews, & Kelly, 2007). Individuals who are gritty display persistent interest in achieving their goals, even when faced with considerable obstacles (Duckworth et al., 2007), and have a greater ability to make meaning out of their lives (Duckworth & Gross, 2014). Indeed the process of making meaning out of life is a crucial aspect of post-traumatic growth, and facilitates positive psychological changes (Blalock, Young, & Kleiman, 2015). Grit has recently been shown to buffer the relationship between negative life events and suicidal ideation (Blalock et al., 2015), and has recently been associated with greater engagement in health behaviours (Reed, Britschet, & Cutton, 2013) and greater retention in dangerous military settings (Eskreis-Winkler, Shulman, Beal, & Duckworth, 2014). Thus, individuals with high levels of grit are likely to persevere during difficult situations, generate meaning from their difficulties, and engage in positive behaviour changes. No research to date has explored grit among North Korean refugees. This may be an important area of research, given that many North Korean refugees content with daily adversities such as unemployment, post-traumatic stress, bereavement, and depression. Further, given the protective role of grit against suicide, it may be important to identify factors associated with increased grit among this group. Identification of such factors may have treatment implications for North Korean refugees. 

Hardiness refers to an individual’s tendency to adapt to, or resist stress (Lambert Jr & Lambert Jr, 1999). Hardiness involves the three distinct facets of control, commitment, and challenge. Specifically, individuals with high levels of hardiness feel they can influence outcomes, possess an exploratory attitude toward living, and are motivated to pursue a meaningful life (Lambert Jr & Lambert Jr, 1999).  Hardiness plays a protective role against the development of PTSD (King, King, Fairbank, Keane, & Adams, 1998).  Further, hardiness has been associated with reduced psychological burden following combat stress among Afghan soldiers (MAPsS, 2004), and the use of active, problem-focused coping strategies among problematic alcohol users (Maddi, Wadhwa, & Haier, 1993).  Hardiness has been viewed as having similar benefits to post-traumatic growth, in the sense that hardy individuals thrive and generate meaning from adversity (Lambert Jr & Lambert Jr, 1999).  There is currently no research exploring factors associated with hardiness among North Korean refugee. Due to the importance of hardiness is facilitating outcomes observed in post-traumatic growth, its negative association with PTSD, and its link with increased problem-focused coping, it is important to investigate the association of this construct with positive psychological outcomes among North Korean refugees.  

Experiential Avoidance
Experiential avoidance is a behavioural regulation strategy that refers to an unwillingness to experience thoughts, feelings, and bodily sensations (Hayes, Strosahl, Wilson, & Bissett, 2004). Experiential avoidance is a maintaining factor in psychological disorders such as depression, the anxiety disorders, and PTSD. Specifically, experiential avoidance has been associated with greater symptom severity among trauma survivors with PTSD (Marx & Sloan, 2005). Experiential avoidance has also been associated with greater distress, and reduced quality of life among survivors of the Kosovo War (Kashdan, Morina, & Priebe, 2009).

Experiential avoidance has been addressed therapeutically through Acceptance and Commitment Therapy (ACT). The positive changes observed through ACT have been measured with the Acceptance and Action Questionnaire, which assesses an individual’s willingness to embrace the full range of emotions, engage in productive, meaningful activities, and reduce their struggles with internal experience (Kashdan et al., 2009). The rationale of ACT is not necessarily to help individuals become symptom-free, but rather to assist them in changing their problematic relationship with internal experiences (Hayes et al., 2004). ACT may be appropriate for North Korean refugees, due to the fact that many among this group experience persistent thoughts and feelings relating to trauma, their capacity to cope, and family members who were left behind in North Korea. It would be useful to establish whether interventions such as ACT that reduce experiential avoidance lead to greater quality of life and reduced psychological burden among North Korean refugees.

North Korean refugees may experience persistent mental health concerns after departing from their home country. Trauma is a common concern among North Korean refugees, and arises from the extreme adversity these individuals have faced within their home country, during the escape journey, and when adjusting to life outside of North Korea. It is therefore important to identify psychological factors that are associated with greater socio-cultural adaptation, enhanced quality of life, and reduced psychological burden among this group. Given the severity of trauma often reported by North Korean refugees, it may be more appropriate to explore how these individuals can achieve a meaningful and purposeful existence, as opposed to living ‘symptom-free’. Post-traumatic growth is one avenue through which North Korean refugees may obtain the capacity to co-exist with the burden of trauma, though there is a scarcity of research investigating factors involved in the onset, maintenance, and outcomes of post-traumatic growth in this population. Personality traits such as grit and hardiness may also predict positive outcomes among North Korean refugees, although it is unknown how North Korean refugees may develop these traits and indeed whether these traits are predictive of enhanced socio-cultural adaptation and reduced psychological burden. Further, it is unknown how North Koreans make sense of their newfound autonomy, upon arriving in South Korea, and where this sense of autonomy fits within the scaffold of post-traumatic growth. Thus it is the authors hope that the factors highlighted in this paper will spark further research into the unique experiences of North Korean refugees; with a focus on growth rather than symptom burden.

Conflict of interest: None.

1. Amnesty International. International Report 2015/16: The state of the world’s human rights. Amnesty International.

2. Jeon W, Hong C, Lee C, Kim DK, Han M, & Min S. Correlation between traumatic events and posttraumatic stress disorder among North Korean defectors in South Korea. Journal of Traumatic Stress 2005; 18: 147-154.

3. Jeon BH, Kim MD, Hong SC, Kim NR, Lee CI, Kwak YS, ... & Bae MH. (2009). Prevalence and correlates of depressive symptoms among North Korean defectors living in South Korea for more than one year. Psychiatry Investigation 2009; 6: 122-130.

4. Kim HH, Lee YJ, Kim HK, Kim JE, Kim SJ, Bae SM, & Cho SJ. Prevalence and correlates of psychiatric symptoms in North Korean defectors. Psychiatry Investigation 2011; 8: 179-185.

5. Um MY, Chi I, Kim HJ, Palinkas LA, & Kim JY. Correlates of depressive symptoms among North Korean refugees adapting to South Korean society: The moderating role of perceived discrimination. Social Science & Medicine 2015; 131: 107-113.

6. Park K, Cho Y, & Yoon IJ. (2009). Social inclusion and length of stay as determinants of health among North Korean refugees in South Korea. International Journal of Public Health 2009; 54: 175-182.

7. Jeon WT, Eom JS, & Min SK. A 7‐Year Follow‐Up Study on the Mental Health of North Korean Defectors in South Korea. Journal of Traumatic Stress 2013; 26: 158-164.

8. Yu SE, & Jeon WT. Mental health of North Korean refugees in protective facilities in China. Psychiatry Investigation 2008; 5:  70-77.

9. Joseph S, Murphy D, Regel S. An affective–cognitive processing model of post‐traumatic growth. Clinical psychology & psychotherapy. 2012 Jul 1; 19(4):316-25.

10. Tedeschi RG, Calhoun LG. " Posttraumatic growth: Conceptual foundations and empirical evidence". Psychological inquiry. 2004 Jan 1; 15(1):1-8.

11. Hussain D, Bhushan B. Posttraumatic stress and growth among Tibetan refugees: the mediating role of cognitive‐emotional regulation strategies. Journal of clinical psychology. 2011 Jul 1; 67(7):720-35.

12. Teodorescu DS, Siqveland J, Heir T, Hauff E, Wentzel-Larsen T, Lien L. Posttraumatic growth, depressive symptoms, posttraumatic stress symptoms, post-migration stressors and quality of life in multi-traumatized psychiatric outpatients with a refugee background in Norway. Health and quality of life outcomes. 2012 Jul 23; 10(1):1.

13. Lee G. The political philosophy of Juche. Stanford Journal of East Asian Affairs. 2003; 3(1):105-12.

14. Lankov A. The real North Korea: life and politics in the failed Stalinist utopia. Oxford University Press; 2014 Dec 1.

15. Duckworth AL, Peterson C, Matthews MD, Kelly DR. Grit: perseverance and passion for long-term goals. Journal of personality and social psychology. 2007 Jun; 92(6):1087.

16. Duckworth A, Gross JJ. Self-control and grit related but separable determinants of success. Current Directions in Psychological Science. 2014 Oct 1; 23(5):319-25.

17. Blalock DV, Young KC, Kleiman EM. Stability amidst turmoil: Grit buffers the effects of negative life events on suicidal ideation. Psychiatry research. 2015 Aug 30; 228(3):781-4.

18. Reed J, Pritschet BL, Cutton DM. Grit, conscientiousness, and the transtheoretical model of change for exercise behavior. Journal of health psychology. 2013 May 1; 18(5):612-9.

19. Eskreis-Winkler L, Shulman EP, Beal SA, Duckworth AL. The grit effect: Predicting retention in the military, the workplace, school and marriage. Frontiers in psychology. 2014; 5.

20. Lambert Jr CE, Lambert Jr VA. Psychological hardiness: state of the science. Holistic Nursing Practice. 1999 Apr 1; 13(3):11-9.

21. King LA, King DW, Fairbank JA, Keane TM, Adams GA. Resilience–recovery factors in post-traumatic stress disorder among female and male Vietnam veterans: Hardiness, postwar social support, and additional stressful life events. Journal of personality and social psychology. 1998 Feb; 74(2):420.

22. MAPsS CL. Hardiness and transformational coping in asylum seekers: the Afghan experience. Diversity in Health and Social care. 2004; 1:21-30.

23. Maddi SR, Wadhwa P, Haier RJ. Relationship of hardiness to alcohol and drug use in adolescents. The American journal of drug and alcohol abuse. 1996 Jan 1; 22(2):247-57.

24. Hayes SC, Strosahl K, Wilson KG, Bissett RT. Measuring experiential avoidance: A preliminary test of a working model. The psychological record. 2004 Oct 1; 54(4):553.
25. Marx BP, Sloan DM. Peritraumatic dissociation and experiential avoidance as predictors of posttraumatic stress symptomatology. Behaviour research and therapy. 2005 May 31; 43(5):569-83.

26. Kashdan TB, Morina N, Priebe S. Post-traumatic stress disorder, social anxiety disorder, and depression in survivors of the Kosovo War: Experiential avoidance as a contributor to distress and quality of life. Journal of anxiety disorders. 2009 Mar 31; 23(2):185-96.

27. Fledderus M, Oude Voshaar MA, ten Klooster PM, Bohlmeijer ET. Further evaluation of the psychometric properties of the Acceptance and Action Questionnaire–II. Psychological assessment. 2012 Dec; 24(4):925.



Copyright 2017 ADG, SA. All Rights Reserved.  
A Private Non-Profit Agency for the good of all, 
published in the UK & Honduras