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Community Mental Health in South Korea

Challenges and Lessons of Mental Health Reform
  • You-Jin ChungEmail author
  • Ok-Kyung Yang
Living reference work entry
Part of the Social Work book series (SOWO)

Abstract

The predominantly Confucian and Buddhist culture of pre-modern South Korean society viewed mental illness from a folk conception, and this notion has remained in modern-day South Korea. This underlying belief that people with mental illness are morally tainted and dangerous proved to be most challenging when crafting the mental health policies and services in 1995 that were subsequently enacted as the first “Mental Health Act” which transformed South Korea’s mental health system from one where people with mental illness were isolated in a facility to one which seeks to integrate into the community. Since then, the South Korean government put in place the 5-year National Mental Health Promotion Plan in 2011 and 2016 which mainly enhanced deinstitutionalization and mental health in primary care, developing mental health services, delivery system, and human resources (mental health professionals). In 2016, Mental Health Act was changed to “Act on the Improvement of Mental Health and the Support for Welfare Services for Mental Patients” (commonly called as Mental Health Welfare Act) which marked the rebirth of the law reflecting on promoting human dignity, human rights, and recovery-based practice environment. Even though the South Korean government has developed and implemented new act, policy, and plans for improving mental health every five years over the past three decades, new challenges and issues keep emerging – it is necessary to consider the balance between mental health promotion, early intervention, treatment, and rehabilitation. Additionally, efficiency and accessibility of mental health services and services integration should be much improved, and the current mental health services and deliver systems should be examined for further improvement.

Keywords

Community mental health services and delivery system Community mental health team Mental Health Act Human rights Recovery-based practice 

Introduction: “Birth of Community Mental Health in South Korea”

This section presents the historical context of the development of community mental health in South Korea, illustrating mental healthcare reform that progressed from a reliance on institutional care to the current model of community care. It includes contextual and conceptual issues – for example, what we mean when we refer to “mental illness” – which could impact on implementing mental health policy and services for the target population that relies on public care in the South Korean society.

Shift of the Perception of Mental Illness

Mental illnesses are featured as multidimensional aspects which include physical, psychological, as well as sociocultural components. In particular, social perception of mental illnesses has affected the approaches used in the treatment and rehabilitation of a person with mental illness. Societal values shape people’s attitudes toward mental illness, and these attitudes are, in turn, molded by the historical and cultural contexts of each community.

The predominantly Confucian and Buddhist culture of pre-modern South Korean society viewed mental illness from a folk conception that such people were evil or demon possessed; and this notion has remained even in modern-day South Korea. Historically, South Koreans hold a negative and prejudiced attitude toward people with mental illness. They often regarded a person with mental illness to be dangerous and unable to manage his/her life independently (Lee et al. 2000). Until the 1980s, for example, a number of quasi-Christian asylums or illegal “pray houses” would confine persons who were suffering from severe mental illness without any proper medical treatment even though psychotropic drugs had been introduced and the national health insurance set in 1963 was covering psychiatric treatments in private and/or public medical settings. Particularly in rural areas, over 72% of psychotic patients were abandoned at home and seeking help from traditional or shaman practitioners (Min and Yeo 2017).

Even though families recognize that mental illness requires professional help and medical treatment, the person with mental illness was generally hospitalized for a longer period of time as the family assumed the patient would not be able to independently cope with his or her life. Family members were also too weak emotionally to handle the stress after the patient showed schizophrenic symptoms (Lee et al. 2000). The stigma against those affected by mental illness – especially those with severe conditions like chronic schizophrenia – was pervasive in the society. As a result, most of the mentally ill persons were confined in asylums and illegal institutions or abandoned. This underlying belief that people with mental illness are morally tainted and dangerous proved to be most challenging when crafting the mental health policies and services in 1995 that were subsequently enacted as the Mental Health Act. The Act transformed South Korea’s mental health system from one where people with mental illness were isolated in a facility (which resulted in them living apart from society) to one which seeks to integrate, include, and encourage these people to participate in community life.

The Act was enacted as the South Korean society was beginning to recognize mental health as an important issue, with the socioeconomic cost of mental illness increasing due to the rising numbers of persons with mental illness. On top of that, South Koreans were starting to consider the quality of life of the people with mental illness who were confined in asylums or illegal mental institutions after these were reported in a televised program, thus highlighting the need to include the human rights perspective in the national discussion on mental health.

The enactment of the Act has also helped to trigger a change in the perception of mental illness and raised awareness of the concept of community mental health. Firstly, the Act led to “deinstitutionalization,” where treatment was shifted from the asylum to the community. Secondly, the concept of mental illness evolved from pathology to “person-in-environment.” This shifted the focus to the interactions between an individual and his or her environment. Thirdly, the target of intervention was extended to the environment, including individuals, families, and society. Fourthly, the range of social work practice also extended beyond treatment to include rehabilitation and prevention. Fifthly, various services were then needed to cover diverse interventions. Finally, professionals from different sectors were brought together as a community mental health team comprising of a psychiatrist, social worker, clinical psychologist, and nurse, among others. These professionals were stipulated as community mental health specialists in the Mental Health Act. This “Mental Health Act” was amended in 2016, and the title was changed to “Act on the Improvement of Mental Health and the Support for Welfare Services for Mental Patients.” The shortened title of the law is “Mental Health Welfare Act.”

Historical Context of Mental Healthcare Reform

The move to embrace the idea that “community mental health is an ideology” requires a change of perspective when developing an understanding of people with mental problems and encouraging the community to help these people integrate into society (Yang 1996). This shift in emphasis also extends to all activities related to mental health – namely, prevention, treatment, and rehabilitation. In particular, community mental health has spearheaded significant changes in several areas of mental health and social work practice in South Korea since 1995. The enactment of the Mental Health Act, first of all, required a change of perceived attitude of the South Korean society toward people with mental illness. This has proven to be challenging and to take time. Since then, the South Korean government has implemented a long-term mental health plan that provides greater protection of human rights and is moving the mental health system toward a community-based system.

Since 1995, basic community mental health services have been set up in each catchment area around the country. The central government delegated the establishment of community mental health centers to the regional governments. Thereafter, the government provided funds for the development of an infrastructure of community mental health services. In 1998, the South Korean government put in place the National Mental Health Promotion Plan which mainly enhanced deinstitutionalization and mental health in primary care, developing mental health services, delivery system, and human resources. In the two 5-year national mental health plans that have been established and implemented in 2011 and 2016, greater consideration was placed on defining the scope and quality of services to be provided throughout the patient’s lifetime. Holistic support that included the mental health promotion drive for the whole nation and community integration of people with severe mental illness were further enhanced.

Articulation of these long-term plans has led to a marked improvement in the mental health services, its delivery system, and the professional resources. However, raising awareness and encouraging acceptance of mental illness remain a challenge. For example, the epidemiological survey by the Ministry of Health and Welfare reported that 27% of South Koreans experience mental illness at least once in their life, but only 15% of these people seek professional help or mental health treatment (National Health Insurance Service 2014). The utilization rate of mental health services is still much lower compared to other developed countries like the United States (39.2%) and Australia (35%) (Chae and Lee 2013).

Despite considerable improvement in mental health services and policy over the past decades, a few issues must be considered in order to develop the mental health system more effectively and promptly. It is important to both advocate for people with mental illness and educate the community about mental health. The people’s increasing awareness and changing attitudes toward mental illness in the society could play a significant role in the establishment and implementation of mental health policies that advocate for early treatment and further rehabilitation. This will help create opportunities for people with mental illness to interact with others in the community. The South Korean society should focus more on promoting mental health literacy to fight the stigma through public education, research, and training professionals who are able to give a voice to those who are suffering from mental illness. Additionally, the government needs to consider establishing a systemic monitoring system which could improve the integrated current services in the community and address the gaps arising from fragmented services provided by different stakeholders and government sectors (Chae and Lee 2013).

On a positive note, service users (i.e., people with mental illness) and their families (family association) have implemented self-support services and expanded the services particularly for people with mental disorder. Such activities could enhance and ensure the rights of these people and their protection against discrimination. Seocho Recovery Centre, for example, provides a good case study of how NGOs and the government have incorporated and developed a community-based recovery program for people with severe mental illness. This will be discussed in greater detail in section “Best Practice: Seocho Recovery Centre” of this chapter.

Mental Health Policy and Services

This section discusses the three parts of South Korea’s mental health services. The first part of this section describes the service delivery system of community mental health. The second part of this section introduces professionals who are involved in working for the persons with mental illness, named as certified “mental health professionals” – psychiatrist, mental health social worker, mental health nurse, and mental health clinical psychologist. It also illustrates how service consumers (persons with mental disorders and their families) work with those professionals and involve in developing community mental health in South Korea. The last part comments on the current mental health policy and service delivery system by discussing some challenges in terms of the quantity as well as the quality of the mental health services and programs delivered in South Korea.

Community Mental Health Services and Its Delivery Systems

South Korea’s mental health service delivery system in the community comprises of three sectors – namely, the community mental health welfare centers, mental health rehabilitation centers, and the mental medical institutions. These three sectors collaborate to collectively provide mental health services for the prevention, treatment, and rehabilitation of people with mental health issues.

Since the enactment of the Mental Health Act in 1995, the focus of mental health services has shifted to community-based programs including rehabilitation and integration. The first 5-year plan for national mental health promotion, which ensures consistency in mental health care provision at the national level, was established in 1998 (The National Mental Health Commission 2010). Since then, the government has developed and implemented 5-year plans with a long-term view of improving national mental health system. As a result, financial resources for mental health services have increased, and greater emphasis has been placed on mental health promotion and prevention, which is seen as a cost-effective strategy. In 2011, the Ministry of Health and Welfare adopted a 5-year national mental health plan to introduce new services and programs with expanded coverage and services. Additionally, the government strengthened the mental health system nationwide, promoting mental health treatment in proper institutions, developing community-based services based on psychosocial rehabilitation, and putting in place social support for people with mental disorder to integrate into community through the provision of housing, employment, and financial aid (Ministry of Health and Welfare 2014). The current 5-year plan, which runs from 2016 to 2020, focuses on early detection of mental illness and reduction of the stigma against people with mental disorders (Library of Congress 2016).

Overall, services or schemes for people with mental disorder in South Korea cover the following areas: namely, rehabilitation, residence (or sanatorium), employment, income security, and other social services (Roh et al. 2016). These services are regulated in various Acts and Regulations. For example, income security is supported by the National Pension Act, Dependent and Disability Act, and National Basic Livelihood Security Act. To support the employment of people with mental disorder, Mental Health Welfare Act, (It was revised in 2016 and activated in 2017.) Welfare Act for the Disabled, and Employment Promotion for the Disabled and Vocational Rehabilitation Act were enacted. At the community level, those services are delivered by the following three major mental health facilities:
  1. 1.

    Mental medical institutions: these include mental health hospitals and psychiatric clinics (public and private). This is the first line of service, particularly for acute patients who need a diagnosis, medical treatment, or hospitalization.

     
  2. 2.

    Mental health rehabilitation facilities: these provide community-based services (social adjustment training, social skill training, vocational rehabilitation training, etc.) at different centers (e.g., day-care center, group home, short-term/long-term residential rehabilitation center, vocational rehabilitation center, etc.) which help persons with chronic mental illness integrate into society.

     
  3. 3.

    Community mental health welfare centers: these provide integrated mental healthcare services for residents in the community and cover the different levels of intervention to promote people’s mental health over their lifetime. These include preventive intervention for suicide, case management for persons with severe mental illness, services for children and youths’ mental health promotion, integrated services for the addicts, online/call crisis intervention program, etc.

     

The First 5-Year Plan and Its Revision: 1998–2010

Since the first national mental health promotion plan was set in motion in 1998, the South Korean government has revised its mental health policy and plan twice – in 2005 and 2006 (Ministry of Health and Welfare 2006). These revisions included (1) downsizing large mental hospitals; (2) developing new community mental health services; (3) enhancing mental health in primary care; (4) developing human resources; (5) encouraging service users and their families to be involved in developing and providing services and programs; (6) promoting human rights of service users; (7) improving the accessibility of mental health services; (8) developing monitoring systems; and (9) financing.

Among these plans, downsizing of large mental hospitals was the most challenging and controversial issue. It was reported that a considerable number of mentally ill patients were hospitalized for longer period (Hong et al. 2016), particularly in psychiatric nursing homes or huge mental hospitals which were often located away from the city and were geographically isolated. Additionally, other issues such as the state of the public medical system as well as the patient’s social and family relations also resulted in long-term hospitalization. For example, one of the main reasons the patient’s family resists deinstitutionalization is due to the lack of support systems and programs provided in the community. It is especially necessary to rehabilitate patients who have been hospitalized for a long period so that they are able to adapt to their new life in the community (Kim et al. 1994). Table 1 documents the main reasons for unnecessary long-term hospitalization surveyed by the project team which included mental health professionals and NGO practitioners who have worked together to suggest the community mental health service delivery system (Sin et al. 1994). Based on the report of the research, the team proposed reforming the public healthcare system by setting up necessary mental health services and programs in the community level, which would cater particularly to persons with chronic mental illnesses who were discharged from mental hospitals or psychiatric nursing homes. During the period between 1998 and 2010, a number of services focusing on rehabilitation and integration were developed in the community and provided in different mental health facilities (Jeon et al. 2017).
Table 1

Unnecessary long-term hospitalization of chronic mentally ill patients

Category

Main reasons of extended hospitalization

Suggestions

Family related

No family to live with when they are deinstitutionalized

No place to live in when they are deinstitutionalized

Residential care in community

Caring burden: personnel, cost, time-consuming, etc.

Concerning about the conflicts among family members due to the stress of caring

Community services:

day-care center, case management, and follow-up service

Social/institutional supports for family

Worrying about symptom management/crisis situation

Crisis intervention

Concerning about relapse due to irregular medication

Follow-up service

Misconception: long-term hospitalization is the only way to recover

Family education

Social/community related

No medical insurance (Medicare) for outpatient care

Extend the coverage of Medicare

Protest by community residents

Education and advocacy

Rejection from general hospital due to mental health issue even though the person needs physical treatment for other illness

Development of integrated care system for the person with mental and physical issues

Medical staffs related

There is no case that medical staffs have tried to discharge patients in mental hospital within 3 months

Misconception/misunderstanding that person with mental health issues should be segregated from a society

No particular reason to extend the hospitalization

Educate and train mental health professionals and personnel

(Source: Sin et al. 1994, p. 40)

The Second 5-Year National Mental Health Plan: 2011–2015

In 2011, another 5-year national mental health plan was implemented which identified six areas of mental health promotion (Ministry of Health and Welfare; Seoul National University 2016) – namely, (1) cutting down unnecessary hospitalization and promoting the community-based services; (2) managing the quality of services and programs; (3) preventing and improving mental disorders in different age groups; (4) setting up and managing the system for people with alcohol use disorder; (5) reducing the stigma against mental disorders and protecting the human rights of people with mental illness; and (6) increasing and strengthening the infrastructure and accessibility of services and resources.

During this period of time, the mental health services were expanded in line with the objective to reach out to more persons with mental problems. For example, the number of mental health medical clinics/hospitals including public and private medical institutions grew 1.65-fold, and community-based rehabilitation centers (community mental health welfare centers and mental health rehabilitation centers) increased 4.57-fold during this time (Roh et al. 2016). In particular, the functions and roles of mental health rehabilitation centers were enhanced and expanded to cover various areas of rehabilitation – for example, day-care service, residential care services, vocational rehabilitation services, group home, etc. (see Table 2).
Table 2

Mental health rehabilitation center: services and programs

 

Services and programs

Residential care center

Long-term residential care, daily living coaching, education, vocational rehabilitation training

Community rehabilitation center

Day-care rehabilitation center (social skills training, vocational skills training, employment supporting), group home, short-term residential care

Vocational rehabilitation center

Vocational rehabilitation training and employment support

Rehabilitation center for the addicts

Treatment and rehabilitation training for people with drug, alcohol, gambling, and Internet game addiction

Social enterprise

Consultation, providing information, marketing, and distribution

Other services:

integrated care for people with severe mental illness

Integrated service including residential service, daily living supporting, different types of rehabilitation services

(Source: Jeon et al. 2017, p. 56)

In comparison to the service delivery system of the last decade, various committees at regional and national level were formed, and each facility was to provide unique services based on their functions regulated in the Mental Health Act. On top of that, persons with mental illness and their families (service users) were included as part of the service providers in the system, which was a remarkable improvement in terms of integrating this group of users into the community. Fig. 1 illustrates how various different sectors collaborated and worked together in the provision of mental health services for people with mental illness and residents in the community.
Fig. 1

Mental health delivery system in Korea (Roh et al. 2016, p. 3)

The Third 5-Year National Mental Health Plan: 2016–2020

The South Korean government has obtained the desired achievement in terms of the quantity of services and programs, for example, the number of mental health facilities has steadily increased over the past decade. In 2017, it was reported that the total number of mental health rehabilitation center was extended to over 300 and the number of the mental health welfare centers reached to more than 200 nationwide (Ministry of Health and Welfare 2017). In terms of the quality of services, however, the government is facing new challenges due to emerging mental health issues such as increasing suicide rate, children and adolescence mental health problems, as well as elderly mental health problems. As a result, the government is required to respond by providing services that cover issues that relate not only to chronic mental illness but also to other mental health issues.

Throughout the review and analysis on the previous 5-year plan, the perspective on providing mental health services has been evolved. First, mental health professionals and policy makers have started to think of the scope of the services to be provided and to consider the services that would cover different issues encountered throughout one’s lifetime. The services are provided based on the four stages of life cycle: infant and toddler (0–6 years), children and adolescents (7–18 years), young and middle-aged adult (19–64 years), and old age (65 years and above). The other notable change relates to the concept of mental health intervention. This is now divided into three levels of prevention including primary, secondary (treatment), and tertiary prevention (rehabilitation) (Roh et al. 2016). The key policy targets four areas including management of addicts and suicide prevention, and the first and the second policies particularly improve mental health promotion (for the whole nation) and community integration (for people with severe mental illness) (see Table 3). These goals can only be achieved through multiple strategies and tasks that require the involvement and collaboration of a number of government ministries. For example, National Human Rights Commission (NHRC), Ministry of Government Legislation, Ministry of Education, and Ministry of Employment and Labour need to work closely together to improve awareness of discrimination against people with mental disorder (National Policy Steering Committee 2016).
Table 3

Integrated policy for mental health promotion

Policy

Strategies

Tasks

Mental health promotion

Promote the accessibility of mental health service

Improvement of accessibility of mental health services

Improvement of the national attention on mental health

Improvement of the discrimination toward mental illness and the mentally disabled

Strengthen the strategies for early interventions

Strengthen community services for depression and anxiety

Support the management of high-risk group with stress

Strengthen the crisis intervention support for victims of disaster

Set the mental health support system over the life-span

Support for infant/early childhood mental health

Support for children and adolescents’ mental health

Support for young adults and adults’ mental health

Support for the elderly’s mental health

Community integration for people with severe mental illness

Intensive care in the early stage to prevent chronic illness

Improvement of the national health insurance: medical cost for psychiatric treatment

Development of care management model for the index case

Improve quality of life of persons with chronic/severe mental illness

Development of community support system

Increase of the number of mental health welfare center and improvement of quality of services

Re-establishment of the functions of mental medical institutions and psychiatric nursing home

Strengthen the human rights of the mentally ill

Improvement of the regulation of admission and discharge process

Empowerment of the self-determination of the mentally disordered

Improvement of the human rights of patients in mental medical institution and psychiatric nursing home

(Source: Hong et al. 2016. p. 10)

Throughout the implementation of the national mental health plans over the past 20 years, the approaches to delivering services have evolved from traditional service provider-centered to service user-centered. One of most considerable attempts made was the adoption of the voucher system. The government provides financial assistance to service users (i.e., people with mental illness and their families) through the provision of vouchers which enabled them to choose services or programs that meet their needs. This new initiative had a spillover effect on other aspects of the service delivery system. For example, the services were replicated on a massive scale as each regional government was required to develop and implement new services that would be more relevant and necessary for the residents. Additionally, the services and delivery system were regularly evaluated and modified based on feedback and comments from the service users, which contributed to an improvement in the quality of services (Yang et al. 2010).

Community Mental Health Professionals and Social Workers

One of the noticeable achievements was effort to put in place the legislation that establishes the accreditation system for nurturing mental health professionals. Mental health professionals receive specialized mental health training at least 1 year after they are qualified in their own professions as social workers, nurses, or psychologists. As of 2013, over 300 centers have trained mental health social workers, mental health nurses, and mental health clinical psychologists. According to Chae and Lee (2013), a total of 11,233 mental health professionals received their certificate over the 15 years since the accreditation system was adopted in 1997.

According to the Ministry of Health and Welfare, there were 27.07 mental health professionals and nonprofessionals employed at private and public facilities per 100,000 population in 2005. They include psychiatrists, other medical doctors, nurses, psychologists, social workers, and other mental health workers (Ministry of Health and Welfare 2006). In 2013, the total number employed in mental health facilities nationwide was over 20,000, a considerable increase in less than a decade (The National Mental Health Commission 2014).

Throughout the whole recovery process, social worker has a strong involvement in providing various services and programs both at hospital and community. During a 6-month stay maximum at hospital, the patient receives mental health social worker’s group activity therapy including individual counseling and family counseling. Social worker’s role takes place after the discharge to community. Community mental health centers and social rehabilitation centers are the core places to provide well-designed community care services including vocational rehabilitation. A typical process of social worker’s involvement in recovery process is illustrated in Fig. 2.
Fig. 2

Mental health social workers’ involvements in the process of the recovery

Another group actively engaged in community mental health is service consumers (i.e., persons with mental illness) and their family members. They are not professionals but have been much involved in developing and improving the self-support services in the community – and especially those related to advocacy of the people with mental disorder. They also work with other mental health professionals to develop legislative activities to strengthen human rights and enhance the protection of the mentally ill from social stigma and discrimination. The Incorporated Korea Family Association For The Mentally Disordered was founded in 1995 when the Mental Health Act was enacted, and this association has worked particularly for rehabilitation of persons with mental illness in terms of vocational rehabilitation and employment, as well as educated the community for awareness of mental health and the social stigma against the mental illness.

Challenges of Community Mental Health Services and System in South Korea

Even though the South Korean government has developed and implemented new policy and plans for improving and promoting mental health every 5 years over the past three decades, new challenges and issues keep emerging that require the government’s attention. To ensure that the public health system meets people’s mental health needs – in particular, those with mental disorder – it is necessary to consider the balance between mental health promotion, prevention, early intervention, treatment, and rehabilitation. Additionally, efficiency and accessibility of mental health services should be much improved to reduce the length of hospitalization or institutionalization both at the service consumer (i.e., people with mental illness and their families) level and the service provider level. Development of comprehensive and accessible services is the cornerstone of mental health policy, and the service delivery systems built on adequate infrastructure are the prerequisites for the consistent care of people with mental illness. Based on these assumptions of desirable mental health services and systems, the current mental health services and delivery systems should be examined for the further improvement.

In South Korea, services for people with mental illness are administered by various government branches including the Ministry of Health and Welfare, Ministry of Labour, Ministry of Unification, Ministry of Justice, Ministry of Education and Human Resources Development, and others. There is thus a certain degree of redundancy in the services provided by different stakeholders in both the public and private sectors. This is another challenge in the provision of community-based services. The collaboration among stakeholders – government, NGOs, private organizations, etc. – is desirable and should be further strengthened to ensure better integration of all community services. In sum, the mental health service system in South Korea should enhance the coordination not only between medical services and other community services but also between private and public service providers. The other challenge in improving the mental health system is the lack of integration between mental health services and the general healthcare system of the country, and this may have inadvertently reinforced the social stigma associated with mental illness and the persons with mental illness. To address this, the South Korean government needs to establish and implement a systematic monitoring system using an evidence-based approach to help mental health professionals deliver the required services more efficiently. Another discrepancy that policymakers should pay attention to is the tendency for most mental health professionals and facilities to be located near the city, which has created an uneven and inadequate services delivery system where persons with mental illness who live in suburban area are not able to receive the much needed services.

Despite some challenges and limitations of the current mental health services system, there are a number of strengths. Firstly, South Korea has developed and implemented legislations and a mental health policy since 1995. It has collected and updated data related to mental health every year, making it possible to evaluate national-level statistics in the mental health area. Secondly, South Korea has built up a pool of mental health professionals, and a number of them are specially trained in community mental health practices. The most significant improvement is a shift of perspective from an institutionally based system to a community-based and public mental health system.

Mental Health Act and Human Rights

South Korea’s National Assembly passed the Mental Health Act on December 30, 1995. The Act took effect on December 31, 1996. Although it was enacted, the Act still held many pitfalls (Yang 2006). While some people approved it, many had opposed the Act. Among those who opposed the Act, some had taken issue with certain articles of the Act, while others rejected the Act itself. This unhappiness led to the first amendment of the Act in 1997, the first year that the legislature was enforced.

The main objection to the Act arose from the possibility of human rights violation and the degradation of psychiatric treatment. Many scholars held conferences and expressed worries over the possibility of involuntary hospitalization, which could happen to almost anybody. Lawyers, psychologists, and psychiatrists sent their written concerns to the press (Dong-A Ilbo 1995; Hankyoreh 1995, 1996). These writers raised two points: the first was with regard to the subjects of the Act, while the second focused on the admission process to a mental hospital.

In fact, the enactment of the Mental Health Act caused an upheaval in the field of psychiatry. Although there were opposition and concerns raised regarding the Act, it was clear the Act had provided greater clarity to the concept of community mental health. Before the Act, community mental institutions were mostly made up of mental hospitals, mental asylums, and homeless shelters. These facilities enabled the mass detention and segregation of mental patients from society so that the rest of society would be protected. With the advent of the Mental Health Act, the basic direction of community mental health policies was given more concrete form and set in motion. The main theme of community-based mental health policy was to support appropriate treatment, adequate care, and active social rehabilitation. The era of community mental health had begun.

The Act was revised several times with minor changes. Enormous changes were made during the 2016 amendment, which saw a change to the title of the Act. This marked the rebirth of the law. The current title is Act on the Improvement of Mental Health and the Support for Welfare Services for Mental Patients. The shortened title of the law is Mental Health Welfare Act.

Revolutionary Changes: Mental Health Welfare Act

The most profound reason for the 2016 revision is the constitutional discordance adjudication of the Constitutional Court. In September 2016, the Court of nine judges decided unanimously to adjudicate the constitutional discordance on involuntary hospitalization by legal guardians. The Court concluded that this type of involuntary hospitalization limits the mentally ill person’s freedom and lacked the necessary provisions to prevent misuse or exploitation of involuntary hospitalization. This constitutional discordance adjudication provided the impetus for the National Assembly to pass the amendment. The new Act was activated in May 2017 and has been hailed as revolutionary, because it brought reform in the following five areas: “human rights,” “community mental health,” “government initiatives,” “social welfare services,” and “(mental health) professionals.”

Human Rights

Human rights is the key ideology in this 2016 revision. In Article 2, “human dignity and value of the mentally ill person” is guaranteed. In doing so, the Act directs the heads of each mental health improvement facility to endeavor to ensure human dignity (Article 6) and to be educated in human rights (Article 70). The law defines the mental health improvement facility as a mental medical institution (i.e., mental hospital), a mental health sanatorium, or a mental health rehabilitation facility (Article 3). Consequently, doctors, nurses, social workers, and all general personnel attached to such institutions are required to attend educational programs on human rights. Otherwise, they will be suspended or their employment revoked.

Along with this, Article 69 emphasizes the protection of rights and interests. “No person shall restrict any person’s opportunities for education, employment, or the use of a facility, deprive any person of such opportunities, or otherwise treat any person unfairly on the ground that the person is or was mentally ill.” Moreover, the head of a mental health improvement facility shall not force labor on any person with mental illness. Such responsibility is required not only at an individual level but applied at the national and governmental levels as well. Additionally, both national and regional governments should include human rights protection plans in their national and regional mental health plans (Article 7).

Community Mental Health

Community mental health is emphasized in these six articles. It appears first in Article 2 (fundamental concepts), where it was stated that hospitalization or institutionalization should be minimized and reiterated the preference for community-based treatment to be recommended and encouraged. It is clear from here that South Korea was declaring community mental health practice to be the core service for people with mental illness. When a nation formulates a national mental health plan, rehabilitation in the community should be emphasized (Article 7).

Article 3 defines a mental health welfare center as an institution for promoting and providing community mental health services in the community. More importantly, it states that persons with mental disorders should reside in the community (Article 37). It is also the government’s responsibility to provide assistance. So, when mental hospitals and institutions provide services, they need to recognize that their services are community-based (Article 21, Article 27).

Government Initiatives

Every 5 years, the government takes the lead in formulating a master national mental health plan for improving mental health and providing welfare services to persons with mental illness (Article 7). Based on the national plan, each regional and local government outlines an implementation plan every year (Article 8). The national plan or regional plan should include the following: (1) activities for preventing mental diseases, counseling, medical treatment, and rehabilitation and interconnection of such activities; (2) services for improving mental health according to the stage in the life cycle – such as infancy, childhood, youth, middle age, and old age – and by gender; (3) early discharge of persons with mental illness and rehabilitation into society; (4) securing and operating appropriate mental health improvement facilities; (5) plans for education, public relations activities for improving awareness of mental diseases, guaranteeing legal rights of persons with mental illness, and protecting human rights; (6) training and managing specialized human resources; (7) plans for improving education, dwelling conditions, working conditions, etc., for improving mental health and for cooperating with relevant government agencies or institutions; (8) establishing and utilizing an information system for mental health; (9) support for persons with mental illness and their families; (10) rehabilitation in local communities and social participation, including health, employment, education, and dwelling conditions of mentally ill persons; (11) matters regarding the research, development, and evaluation of welfare services for persons with mental illness; (12) matters regarding the procurement and management of funds necessary for rendering welfare services to persons with mental illness; and (13) other matters that the Minister or the mayors may decide.

Social Welfare Services

Chapter IV, a newly added chapter in this revised version of the Act, prescribes the range of welfare services. This is why the new Act is commonly called the Mental Health Welfare Act. This chapter has six articles – namely, Articles 33 to 38.

Article 33 delineates the development of welfare services; Article 34 outlines the assistance in employment and vocational rehabilitation; Article 35 looks at assistance in lifelong education; Article 36 discusses assistance in cultural, artistic, recreational, and sports activities; Article 37 proposes integrated assistance for dwelling, medical treatment, and rehabilitation at local community; and Article 38 looks at the provision of information and education to families.

The revised Act is revolutionary in the sense that it outlined a mental health regime. Besides, lifelong education and employment for the persons with mental illness are also supported. More importantly, cultural, artistic, recreational, and sports activities are maximally ensured. And employment is considered as vocational life that makes the best use of capabilities of persons with mental illness. The government also provides the necessary information and education for family members to jointly support this endeavor. The community is recognized as a center for integration of persons with mental illness to society and the hub for all these activities. Additionally, the legal provision emphasizes that the mentally ill person needs to dwell and receive medical treatment in the local community, rather than isolated mental institutions.

Currently, in South Korea, there are 225 mental health welfare centers including the mental health improvement facility (previously known as the community mental health center) (Ministry of Health and Welfare 2017). There are also 336 mental rehabilitative institutions providing a range of rehabilitative services for 4,646 users and 2,039 residents in living facilities.

(Mental Health) Professionals

Under the law, the Minister of Health and Welfare issues a license to qualified professionals. Article 17 refers to them as mental health specialists, and they are classified into mental health social worker, mental health clinical psychologist, and mental health nurse. As of December 2016, there was a total of 18,264 certified or licensed mental health professionals. Among these are 3,078 mental health clinical psychologists, 5,244 mental health social workers, and 9,942 mental health nurses (Ministry of Health and Welfare 2017).

Hope for the Future

Several changes in the new Act were aimed at improving the quality of treatment. The Act emphasized community mental health and highlighted government initiatives in the provision of social welfare services. All this was aimed at the protection of human rights. The essence of the change was to promote human dignity: namely, less restriction and more freedom. The Act emphasized no forced labor under any circumstance and more opportunities for education employment and community living.

The new Act also made involuntary commission to mental hospitals more difficult, requiring a consensus among two or more psychiatrists working in two different mental health institutions (Article 43). The length of hospitalization was limited only 3 months or less, whereas the previous Act had no limit on the stay. Involuntary admission rate in Korea is relatively high. Among all admissions, 67% is involuntary, while the rate in Germany is 17%, 13.5% in Great Britain, and 12% in Italy (Ministry of Health and Welfare 2017). The new law is aimed at reducing unnecessary involuntary admission, while the community-based social welfare services delineated in the Act were aimed at reducing admissions and promoting a humane life. Since the first enactment of the Act, institutions detaining patients such as the mental health sanatorium were reduced. In 1994, there were 76 sanatoriums with 18,168 beds (Minstrey of Health and Welfare 1995). This dropped to 59 sanatoriums with 13,519 beds in 2017 (Ministry of Health and Welfare 2017). Various community-based mental health centers were also created and increased throughout the years. There are now 606 community-based mental health centers with 96,000 persons with mental illness who have used the services since 2016.

With the revised Act on the Improvement of Mental Health and the Support for Welfare Services for Mental Patients, it is now mandatory to build an environment to promote human dignity and the human rights of the population with mental health issues. Mandatory education on human rights to all staff members, including the heads of institutions, is expected to promote a human rights-based practice environment. The governmental initiative of setting up the social welfare programs will help speed up the development of a human rights-based environment. Now that the system is set, the onus is on those who operate the system. They will need to change their perspectives, reflect on and check their prejudices against the mentally ill, and provide them with ample space to join the society.

Best Practice: Seocho Recovery Centre

As of 2016, there are 336 mental rehabilitative institutions nationwide (Ministry of Health and Welfare 2017). Seocho Recovery Centre (or SRC), “Open World”, one of the social rehabilitation centers, was established. It is a day rehabilitation institution for persons with mental disorders located in Seocho District in Seoul, South Korea. It was established in 2001 by the Sarang Welfare Service Foundation and has funding support from the city and the local government. Since its opening, SRC set the center’s core values as “recovery” and “human rights” and focused on clients’ self-determination for their recovery plan. All the staff members have a strong belief in recovery paradigm within the human rights practice. The client is understood as a service user and is referred to as a “member.”

SRC’s active members are 35. They are 30 service users and 5 to-full-time staff members including a director and 2 trainees to become mental health social workers and 2 mental health social workers. SRC is supported by the steering committee consisting of a social work professor, an attorney, one SRC member, and one family member. A psychiatrist is also on duty for consultation. Of the 30 service users enrolled in the SRC, 11 are employed, 3 are working as peer support workers, and the rest are involved in various kinds of individually tailored programs for recovery.

From the beginning, SRC provided education to clients, utilizing education materials from the United States (Personal Assistance in Community Existence and A New Vision of Recovery), England (100 Ways to Support Recovery of Rethink Mental Illness series), and World Health Organization (QualityRights). Through those materials, the service users began to understand what the recovery from mental disorders was and how and what should be done to accept the recovery concept in mental health area. SRC service users and staff members studied those materials together and transformed the contents for their own use. SRC runs several programs directly or are assisted by the service users. Currently, five programs are in active operation.

Human Rights Program

Human Rights Program (HRP) is the core of all programs in SRC. From the beginning, members develop a two-way communication and cooperative relationship. The core value is that a service user increases his or her capacity for self-determination and advocacy under the assistance of staff members, who ensure that the development is in the right direction.

In 2009, SRC conducted a project named “Chance, Change, and Challenge!!!” The project consisted of human rights education, human rights conference, human rights monitoring in ordinary everyday life, and human rights advocacy products. The empowerment approach was practiced to raise self-empowerment and ensure self-determination among the service users. It encouraged this practice not only in SRC but also in the patient’s home and other living environments. For the staff members, competency enhancement program was developed to learn a human rights-based practice.

HRP is now successfully embedded in all programs at the SRC. All SRC members are now more sensitive toward the human rights of persons with mental disorders. The members also produced a guidebook and a story-telling book. Rights and Resources Guidebook is a resource book about the inherent rights and the rights to access the resources. Younghee’s Story is a semidocumentary, story-telling human rights book that tells the story of a young woman’s life journey from the onset of mental illness to recovery. SRC continues to promote the human rights of persons with mental disorders in society and to the public.

Wellness Self-Management

Wellness Self-Management (WSM) is a key program designed for regaining insight and recovering self-management capability among the service users. SRC members adopted seven dimensions for recovery: the belief for recovery, symptom management, physical health, emotional health, cognition, vocational issues, and finance. Based on the WSM manual, SRC members shared the information, specific methods, and skills for coping with the symptoms and/or hardships of everyday life. These processes were reviewed with the members – staff and service users.

WSM is now spread to more than 20 institutions, including day social rehabilitation centers and mental health clinics. SRC staff members and service users educate and supervise those institutions for the use of WSM. It is another positive result of utilizing WSM from the perspective of the service users.

Peer Support Program

The Peer Support Program was recently developed but is very actively operated. It is a program to train a service user to become a leader in their issues and challenges so that they can stand up for themselves. It also educates them to teach their colleagues. Some of the subprograms are “Peer-Run Program,” “Self-Help Group Program,” and “Peer Counseling Program.” The program is funded by the Seoul Metropolitan Government. When the service users successfully finish the program, they can be appointed as a peer support worker and paid for 1 year. And it is also funded by the Seoul Metropolitan Government. Three of the SRC members are working actively as peer support workers.

Social Co-op MOA

SRC established a social co-op MOA in 2015 with three other social rehabilitation centers. It is named MOA, which is a newly created word meaning essentially a gathering to welcome people to their co-op. It is run directly by the persons with mental disorders and their family members, along with mental health social workers. There are currently 48 people involved.

MOA is set up to approach the employment and living arrangement problems in the community. The main goal of this co-op is independent living in the community. SRC took the initiative to set up MOA. The first achievement was the setting up of a job site. It opened a MOA café #1 at the lobby of the National Centre for Mental Health with funding support from the Community Chest of Korea. The café #1 now has eight persons with mental disorders as its employees. MOA is preparing to launch café #2 at a private company. MOA’s next task is housing. They plan to set up social housing with a concept of a shared house and supported housing.

Café “JoEunHaRu”

Café JoEunHaRu is located in the lobby of the community social welfare center where SRC is located in. JoEunHaRu means “good day.” It was established in 2005 to provide training in service delivery and for barista education. Education and training are provided by professionals and managers. Several hundreds have participated in this program. However, only a few participants took the barista license. Some have gone on to open cafés, while others were hired by commercial cafés in the community, such as Starbucks.

Conclusion: Paradigm Shift – Beyond Hospital in the Community

Until recently, mental patients with psychotic symptoms were kept behind the scenes. They were treated either as idiots or fearful persons. Once such a patient was committed to a psychiatric hospital or a mental asylum. They stayed forever or were moved around from one institution to another and were allowed limited contact with family members. Inside the institution, these patients were put together with many other patients and locked up like inmates. They were also forced to do hard labor instead of being treated and cared. The basic necessities of life – food, clothing, and shelter – were below average.

In 1984, the Korean TV report “Chujeok 60 Mins” exposed these cruel conditions. The awareness of inhumane condition sped up the enactment of the Mental Health Act of 1995. It became regarded as a watershed, as it represented a turning point where psychiatry was overtaken by an emphasis on mental health and the locus of care for the people with mental illness moved from institutional care to community care.

The enactment of the Mental Health Act gave rise to the concept of community mental health. The mental health policies were formulated based on the Act, and the community responded rather quickly with a positive reaction. The community mental health orientation was introduced, and the programs and services were developed. Society slowly geared toward the direction of community mental health, although it was assumed, at the beginning, as a simple change in the residential arrangement – namely, from asylum to community.

Since then, social rehabilitative programs sprung out everywhere in the community of South Korea. The newly set up mental health policies allowed the government to provide financial support for the establishment of social rehabilitation facilities and to subsidize the programs and personnel expenditures. The Act also created professional positions such as mental health social worker, mental health nurse, and mental health clinical psychologist. Among these mental health professionals, particularly social workers who already had a community base with clients, were actively involved in creating and providing the programs for the mentally ill patients who were discharged. For example, the “Hanultari (One Boundary)” and Seodaemun-gu Community Mental Health Centre Model Program were social work-based rehabilitation programs that were provided in the community social welfare center (Yang 1996). These programs were launched even before the enactment of the Act and took off in earnest after the Act came into effect.

When community mental health first took root, South Korea, like other forerunning countries, focused on rehabilitation in community. Regaining social functions was the main focus. The programs and services at the facilities were grounded on the concept of symptom reduction and management along with the elimination of disabilities and handicaps. Until then, the professional society still hung on to their negative perspectives of the mentally ill and community mental health. It was only at the beginning of 2000, when the recovery model was introduced and practiced, that society slowly came around to a more positive notion of community mental health (Rosenberg and Rosenberg 2006). At the time, mental health professionals did not realize that community mental health is a revolutionary change from the ideology of psychiatric treatment (Yang 1996; Suh 1999). As they met with patients in the community, they began to realize that the social rehabilitation programs were just the same programs with a mere change in the location for the provision of services. Such an awareness led to the recovery paradigm.

Recovery is understood as an ongoing process, not an end goal. Conceptually, recovery refers to “controlling symptoms, regaining a positive sense of self, managing stigma and discrimination, and trying to lead a productive and satisfying life” (Markowitz 2005, p. 86). Since it is a very complicated concept, recovery is delineated in multilevel contexts. The levels are considered in symptoms, self-concept, and social and economic well-being. Four dimensions were developed to aid the understanding of recovery (Liberman and Kopelowicz 2005). These dimensions are psychotic symptoms, independence, work or school, and social and recreational activities.

The essence of the recovery-based practice is “person” and the person’s everyday life with mental illness. Mental illness is the illness that the person can handle and manage like all the other physical illnesses such as diabetes or heart diseases. It is not the illness that one has to be afraid of. The Korean society has slowly moved forward in accepting the concept of recovery, and the community mental health programs in South Korea are pursuing to focus on enhancing the resilience to manage mental disorders and the capacity to cope with various challenges in everyday living situations. Given that this recovery-based practice has been pursued and developed in the community setting in South Korea, mental health professional assistance offered to the persons with mental issues also focuses on the their self-management skills and simultaneously promotes their dreams and aspirations, which is considered as a human rights-based practice. The recent revised Act reflects the recovery-based and human rights-based practices to promote human dignity and the human rights of the mentally ill population.

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Copyright information

© Springer Nature Singapore Pte Ltd. 2019

Authors and Affiliations

  1. 1.Social Work Programme, S R Nathan School of Human Development Singapore University of Social SciencesSingaporeSingapore
  2. 2.Department of Social Welfare, College of Social Sciences Ewha Womans UniversitySeoulSouth Korea

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