Psychological Outcomes for North
A Research Agenda
of Psychology, Macquarie UniversityEmail:
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.
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.,
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
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).
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
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.
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.
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.
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
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