Culture in Anger Disorder as Culture-Bound Syndrome

I. Introduction

For many, anger has been seen as irrationality, even as illness.¹ But anger is biologically and universally valuable as well because it enhances fitness by detecting aggression or threats and facilitating cooperation. Can excessive or malfunctioning anger be seen a matter of mental illness? It seems that anger-related disorder and its culture-relatedness have not receive much attention in psychiatry. Like backward-looking ressentiment, hwabyeong 火病 (often Romanized as “hwa-byung” in the literature) can be literally translated into “anger disorder.” In this paper, I examine the notion of anger and culture with the help of considering the case of hwabyeong as a Korean culture-bound syndrome (hereafter, CBS). Indeed, it is a common view that many psychiatric disorders cannot be properly understood without certain sociocultural contexts. Drawing on historical changes in the Diagnostic and Statistical Manual of Mental Disorders (DSM) and cases of hwabyeong as CBS, I will argue that the social and cultural aspects of mental disorder are indispensable parts. Additionally, it will be suggested that the rigid distinction between CBS and mental disorders is questionable. In this paper, my focus is mostly concerned with cultural causation and social conditions of hwabyeong in Korea. This question will also have several implications on the question of whether hwabyeong is culturally bound.

First, before discussing hwabyeong, I begin by examining Jarome Wakefield’s harmful dysfunction (hereafter, HD) analysis and Ian Hacking’s social constructionism on mental disorder. This is because Wakefield and Hacking’s views on mental disorder provide us some conceptual resources to understand the conception of hwabyeong as CBS. Next, given that the illness is common among poor old women who suffered from patriarchal social structures, I question whether hwabyeong is really a culturally specific illness. Moreover, hwabyeong cannot be properly understood without considering unequal power relations and extremely limited ranges of one’s agency. Thus, calling it culture-bound may be due to WEIRD-ish (Western, Educated, Industrialized, Rich, and Democratic), culturally stereotypical prejudice as well as misogynic thinking concerning hwabyeong. It is worth noting that, despite common biases, hwabyeong or han (恨) is no longer solely a Korean phenomenon, thanks to recent societal advancements. In conclusion, I show that curing hwabyeong or anger management is not just a medical but a sociopolitical matter.

II. Defining Mental Disorder with the Help of Culture

In this section, for a viable definition of mental disorder, I will examine Wakefield’s harmful dysfunction analysis. For many, psychiatry is regarded as a naturalistic investigation of mental disorders. Wakefield believes that the HD model has better explanatory power over other rival accounts insofar as it connects a value term (harmful) to a scientific factual term (dysfunction). He writes: “According to the HD analysis, a disorder is a harmful dysfunction, where “harmful” is a value term, referring to conditions judged negative by sociocultural standards, and “dysfunction” is a scientific factual term, referring to failure of biologically designed functioning” (Wakefield 2007, 149).² He admits a role of sociocultural standards by using the concept of “harmful” but rejects a pure social constructionism by referring to the idea of “dysfunction.” In sum, something counts as a mental disorder if and only if it is both harmful and dysfunctional. Through the HD, Wakefield tries to develop a two-tier model by attempting to bridge the gap between constructionism and naturalism.

While mental disorders are usually considered harmful, it is important to note that there are many harmful or negative cases that are not disorders. Disorders can be a failure of certain natural function be it psychological or physiological. What Wakefield wants to appeal to is the factual component, that is, definitive etiological understanding of mental disorder. In distinguishing disorder from non-disorder, this factual component comes down to a dysfunction, in other words, a failure of natural functioning. For him, dysfunction is the failure of an internal mechanism to perform certain naturally selected functions. When it comes to the distinction between normal sadness of mourning and disordered sadness, for example, Wakefield thinks that a “purely value-based account of ‘disorder’ does not explain such distinction among negative conditions” (Wakefield 2010, 287). In sum, he claims that natural functions can be objectively accountable since our psychological and physiological functions are naturally selected for certain evolutionary purposes.

In addition, Wakefield embraces a value-laden part along with a factual part about dysfunction. If there is a condition that involves no harm at all, one might count it as mere human cognitive diversity rather than disorder. His analysis is a two-tier and hybrid theory as far as the value judgment of harm constitutes some further criterion to the factual account of dysfunction. The idea is that a society is, at least partially, responsible to delimit the boundary between abnormality and normality, sanity and madness. For example, the occurrence of anorexia is closely related to certain cultural norms valuing thinness as a feminine ideal. But the western ideal of female beauty may not be applicable to African or Asian countries regarding various avoidant/restrictive food intake disorders. Likewise, it is unclear if current American psychiatric methods are equally viable in a Korean context or the United States in 100 years ago.

Concerning the question of whether culture plays a decisive role in the value judgment, Wakefield is very explicit that cultural differences can affect our judgment of something as actually “harmful.” Due to the elusive concept of the disorder itself, the identification of mental disorder requires the standard for judging what mental condition should count as mental disorder in the first place. A dysfunctional condition is a mental disorder when it is considered harmful or negative according to some social values. To show this point, he gives an example of dyslexia, that is, the inability to learn to read, which was not harmful in illiterate societies. If we stick to a purely scientific account of disorder, we cannot understand this value component of the mental disorder. Similarly, consider the case of homosexuality, which has not been considered as a mental illness since the early 1970s. Is homosexuality “sexual dysfunction” due to its failure to perform the natural function of reproduction? At least, it might be argued that it still belongs to dysfunction but fails to count as harmful in the contemporary value system.

However, we might ask how the HD model helps to make genuinely cross-cultural diagnoses. As he shows in his analysis of the cross-cultural use of diagnostic criteria, we can find different gender expectations, youth expressions, and social norms such as individuality in south Korea, Germany, and Taiwan. These cultural aspects should affect the DSM criteria differently. In the next section, I will provide Ian Hacking’s social constructionism.

III. Hacking on Social Construction

If we take the value component of mental disorders seriously, social constructionism emerges as an intriguing option. It seems plausible to consider mental illness, if not somatic illness, to be socially constructed. In other words, a society is, at least partially, responsible to delimit the boundary between abnormality and normality, sanity and madness. For example, the occurrence of anorexia is closely related to certain cultural norms valuing thinness as a feminine ideal. But the western ideal of female beauty may not be applicable to African or Asian countries regarding various avoidant/restrictive food intake disorders. Likewise, it is unclear if current American psychiatric methods are equally feasible in a Korean context or the United States in 100 years ago. If so, it might be argued that current categories of mental disorder do not pick out real kinds of disease. In other words, diagnosis does not “cut nature at its joints” as far as there are no practice-independent or classification-independent joints in the first place.

To be sure, a certain mental disorder is not simply brought into being by our conception about it. Even though depression may be influenced by some sociocultural factors, it might be argued that it is also correlated with serotonin’s abnormal secretion. Here note that I am only concerned with a modest version of social constructionism, which allows room for underlying biological mechanisms. The upshot is that a given society’s specific attention, patterning, and grouping may affect the occurrence of disorder itself. In this regard, one of Hacking’s points is that the socially constructed category of mental illness suggests its changeability, historicity, and instability (1999, 6). According to him, for example, a mental disorder like schizophrenia does not necessarily have to be as it is currently understood, and its characteristics are not inherently predetermined by nature. While schizophrenia may be taken for granted and appears to be inevitable, we may be better off if we remove the category of schizophrenia. If this is the case, we should be cautious not to prematurely reify the current categories of mental disorders.

Unlike natural sciences on natural kinds, Hacking claims that the problem of classification in social sciences on human kinds has a distinctive problem. Whereas the essence of gold can be described as 79 protons, mental disorders cannot be described in such a way due to what Hacking calls the looping effect: “The classification ‘quark’ is indifferent in the sense that calling a quark a quark makes no difference to a quark” (1999, 105). According to Hacking, human kinds are necessarily interactive kinds whereas natural kinds are indifferent to the classification.

We are especially concerned with classifications that, when known by people or those around them, and put to work in institutions, change the ways in which individuals experience themselves—and may even lead people to evolve their feelings and behavior in part because they are so classified. Such kinds (of people and their behavior) are interactive kinds. (1999, 104)

This is the “looping effect” in which the classification interacts with the classified object (in this case, patient’s belief and desire): “to create new ways of classifying people is also to change how we can think of ourselves, to change our sense of self-worth, even how we remember our own past” (1995, 369). The looping effect shows that the conception of such and such mental illness can cause some change in the mental illness itself. As Hacking notes, “what was known about people of a kind may become false because people of that kind have changed in virtue of what they believe about themselves” (1999, 34). Thanks to a causal role of categorization, there is some significant relation between our subjective experience and the conception of mental disorders. According to his “dynamic nominalism,” the act of naming and the actual kind coexist simultaneously. That is to say, “numerous kinds of human beings and human acts come into being hand in hand with our invention of the ways to name them (2002, 113). Before the conception of multiple personality disorder (MPD) is available, for example, we can say that a humankind with MPD does not exist.

It might be argued that autistic children, who have severe communication problems, are a counterexample to Hacking’s claim that mental illnesses are interactive kinds. But it is important to note that this interaction does not have to involve explicit conscious awareness. Even if we see no clear looping effect in the case of individual child autism, his point does still make sense. Hacking writes: “By interaction I do not mean only the self-conscious reaction of a single individual to how she is classified. I mean the consequences of being so classified for the whole class of individuals and other people with whom they are intimately connected” (1999, 115). This assertion suggests that the awareness and intentional internalization of shared norms are not a necessary condition for the looping effect. For it is very unlikely that mentally disordered people intentionally want to imitate people with mental illnesses. The looping effect does not require certain people to consciously know which category they belong to as far as they interact with the categorization in a certain way. This is also consistent with our intuition that mental disorder should be something involuntary and not consciously controlled. Even if some patients are deviants who are violating norms, we should distinguish a failure to conform to a norm (non-disorder) and an inability to understand it (disorder). For instance, people who are deviants in that they violate social norms are not the same as deviants in that they are not statistically normal in their psychological makeup.

The case of childhood autism is particularly interesting because Hacking wants to maintain the indifferent kind as well as interactive kind in considering mental disorder. He says: “let us posit that there is a pathology P, no matter how it will be identified. By hypothesis the pathology P will be an indifferent kind. The neuro-geno-biochemical state P is not aware of what we find out. . . . In more traditional jargon, P would be a natural kind” (1999, 117). Hacking goes on to say that “childhood autism is (is identical to) a certain biological pathology P, and so is a ‘natural’ kind or an indifferent kind. At the same time, we want to say that childhood autism is an interactive kind, interacting with autistic children, evolving, and changing as the children change” (1999, 119). His ultimate position seems to embrace both natural kinds and humankinds. Here natural kinds can refer to common underlying mechanisms across historical and cultural boundaries such as genes. This point is noticeable since disorders can persist across the generations despite sociocultural influences. This suggests there should be some biological abnormalities whereas some of them may be partly cultural products. To reconcile a possible tension between interactive kind and indifferent kind, he appeals to “semantic resolution,” drawing on the causal-historical theory of reference. Regarding autism, Hacking presents the following arguments:

• a) There is probably a definite unknown neuropathology P that is the cause of the prototypical and most other examples of what we now call childhood autism;
• b) The idea of childhood autism is a social construct that interacts not only with therapists and psychiatrists in their treatments, but also interacts with autistic children themselves, who find the current mode of being autistic a way for themselves to be. (1999, 121)

On this account, “autism” refers to the combination of an indifferent kind—the underlying biological pathology—with an interactive kind. This semantic resolution is intended to incorporate two different meanings of causation involved in the investigation of mental disorders: on the one hand, this causal-historical theory of meaning fixes its referent by the causal chain of successive users in a linguistic community. On the other, Hacking’s semantic resolution aims to accommodate a causal power of feedback by reference to the looping effect. If the causal-historical theory of reference is right in this context, the essence of autism would be neuropathological (1999, 121), while its connected meaning may vary in accordance with sociocultural factors. The neuropathological essence amounts to an Archimedean point.

Insofar as Hacking sharply divides indifferent kinds and interactive kinds and does not integrate them into a unified research program, it remains unclear how they can be connected. In Hacking’s picture, even if terms like “autism” are supposed to refer to combinations of natural and social explanations, they seem to remain separated. For him, “some of these interactive kinds pick out genuine causal properties, biological kinds, which, like all indifferent kinds, are unaffected, as kinds, by what we know about them” (1999, 123). It is not clear how “some of these interactive kinds” can be indifferent kinds, and how these two different kinds should be demarcated. Given the fuzzy line between the natural and the social, the boundary between interactive kinds and indifferent kinds may be much more variable and malleable than Hacking supposes. Furthermore, if only biological kinds are “genuine causal properties,” it is hard to know to what extent social kinds have their own causal power. If so, there seems to be a similar problem of the rigid distinction between descriptive (indifferent kinds/dysfunctional part) and normative (interactive kinds/harmful part) properties in Hacking’s view. To be sure, it might be argued that Hacking’s model is much more relaxed than Wakefield’s proposal in acknowledging interactive kinds as the value component. But as far as Hacking wants to maintain this distinction between indifferent (value-free) kinds and interactive (value-laden), his model would amount to another version of two-tier model like Wakefield’s. The issue of causation is different from that of construction, classification, or labeling.

If so, the crucial question regarding social constructionism debates is not to simply choose the causal or the descriptive account of the semantic meaning of mental illnesses. If the genuine issue is the causal interaction between neurological mechanisms and culture via the mental representations, it might not be so important to choose the proper semantic theory to investigate the issue of mental disorders. The genuine issue is to see how culture as a causal factor shapes mental illness. The version of social constructionism as to mental illness we need, in my view, is stronger than merely a semantic one, which is concerned with idea construction. That is, a satisfactory model for mental disorder should consider the relevant causal factors, integrating biological and social factors, not just limited to the issue of reference. My basic point that culture must be considered a serious causal factor of mental disorders, rather than their mere manifestation. To make this point more vividly, I will turn to the notion of anger and disorder in anger disorder in Korea.

IV. Hwabyeong and Cultural Variation

In this section, I will extend my previous discussion by considering culture as a causal factor for giving rise to mental illness. Unlike depression, schizophrenia, or anxiety, which are considered to universally occur in almost every culture, CBS seem to suggest a more profound influence of culture on mental health. They also raise the difficult question of the status of mental disorder and its normativity. A vast range of anthropological literature on cultural variation raises the difficult question of how to conceive the cultural factors in considering mental disorders. An immediate question =is to decide whether the CBS should be considered a distinct category within the diagnostic classification of mental disorders. For many western observers, the CBS such as amok, latah, and koro may seem idiosyncratic, exotic, incomprehensible, and irrational outliers.³ By contrast, even though Multiple Personality Disorder (MPD) was seldom found outside the USA, it was not considered culture-bound. The fact that discussion of the CBS was included as a glossary in appendix I of the DSM-IV suggests the stark dichotomy between universal categories of mental disorders and unique CBS. According to DSM-IV published in 1994, CBS are defined as “recurrent, locality-specific patterns of aberrant behavior and troubling experience that may or may not be linked to a particular DSM-IV diagnostic category” (898, as recited in Murphy 2015). While this definition assumes only the DSM categories are cross-cultural and not culture-bound, it is not clear whether any specific CBS is intrinsically and unquestionably attached to a specific ethnic or cultural group. Instead, we should be non-parochial and dynamic in considering the classification of the CBS in the broader frameworks of mental disorders. It would be deeply misleading if non-Western and non-American Psychiatric Association (APA)-sanctioned mental disorders are simply designated as the CBS. As Charles Hughes writes, “The CBSs are important not as a museum of exotic, static, bounded entities, but as illustrations of a generic way of thinking about relationships between psychopathology and cultural context” (1998, 420).

To see this point concretely, I will briefly examine the case of hwabyeong, a well-known culture-bound syndrome in Korea. hwabyeong was included in CBS when DSM-IV was published. It was thanks to several Korean psychiatrists who tried to relate the indigenous idea of hwabyeong to the DSM’s alleged scientific classification of depressive disorder, thereby establishing it as a legitimate medical condition. As far as “hwa” 火 means anger as well as fire and “byeong” 病 disorder, hwabyeong’s literal meaning would be “anger disorder.”⁴ Hwa’s twofold meaning (fire/anger) is noteworthy since hwabyeong’s common somatic symptoms are heat or hot sensations in the body (often as chest pressure and heart pounding).⁵ Relatedly, anger-related emotional reactions may include eogul 抑鬱 (“feeling unfairness”) or bun 憤 (similar to eogul in the feeling of unfairness but also “eruption of anger”). The terms “Eogul” and “bun” can be translated in various ways, including suffering unfairness, being victimized, being mistreated, being resentful, being indignant, and being sorry.⁶ It is notable that it is sufficient for those who suffer hwabyeong to perceive something being unfair rather than the fact that they are actually a victim of such unfairness. But it should be noted that the gap between the perception of unfairness and the actual happening of unfairness is supposed to be rather exceptional than ordinary.⁷ Interestingly, hwabyeong is likely to develop in situations such as unfair and unjust social environments or stressful relationship such as chronic familial conflicts. Patients with hwabyeong report that they had to “suppress or inhibit their anger, so as not to jeopardize peace in the family or harmonious social relationships or that expression of anger has been blocked” (Min 2009, 13). As a result, suppressed anger gradually accumulates and becomes extremely dense (ul 鬱), accompanying with various symptoms such as somatization, depression, and anxiety. Insofar as an eruption of anger is blocked, hwabyeong is like inactive volcano. While somatic symptoms like respiratory stuffiness seem to be related to the suppression of hwa (“anger/fire”), the coping mechanisms involve crying, sighing, random thoughts, and talkativeness (hasoyeon) (2009, 14).

In his systematic investigations, Sung Kil Min, one of the most well-known experts of hwabyeong, argues for the need for the indigenous research on hwabyeong because genuinely Korean aspects cannot be captured by cultural obstacles inherent in the WEIRD-centered psychiatric studies. He says, “it is problematic that our country’s psychiatrists rely solely on theories of Western Medicine in treating our country’s patients. Socio-cultural factors that cause our patients’ mental illnesses are different from those of (Western) societies. (Our patients’) manifestation of symptoms, ways of expressing them, and methods of treatments cannot be separated from the traditional attributes of our family, society, and culture” (Min 1986, 653).

Min enumerates several culturally specific features of hwabyeong such as shamanism, traditional medicine, a culture of jeong 情 (“love,” “caring,” and “attachment”), collectivism, han (“one,” “big,” and “whole”) philosophy, and fire-likeness. Among others, it would be helpful to consider culture of han as a unique traditional collective sentiment of Koreans. While han’s colloquial meanings are “‘grudge,’ ‘rancor,’ ‘spite,’ ‘regret,’ ‘lamentation,’ ‘grief,’ or ‘hate,’” Min defines han as “a chronic mixed mood of missing, sadness, suppressed anger, feeling of unfairness (‘uk-wool [eogul]’ and ‘boon [bun]’), or ‘everlasting woe’” (Min 2009, 14). Especially, han is an emotional reaction to a tragic national history (Korean War, Japanese colonialism, poverty, etc.) as well as a personal hardship (failed romantic relationships, handicap, chronic disease, etc.). According to Min, han as collective emotion is individuated and embodied in hwabyeong as personal illness. While “anger in haan [han] seems to be more suppressed, passively expressed, sublimated. . . anger in hwa-byung [hwabyeong] is partially suppressed. Haan [han] is a collective, stable and paradoxically somewhat positive emotional state, hwa-byung [hwabyeong] is a form of personal illness” (Min 2009, 15). It is notable that anger is suppressed, not just hidden. Again, what matters is external conditions wherein releasing anger is almost impossible or at least too costly and risky.

When it comes to the etiology of hwabyeong, Min argues that “suppression and control have been strong social codes of behavior in the traditionally familial, collective, and Confucian culture of Korea” (2009, 13).⁸ In this regard, it is not accidental that hwabyeong is most common among older women with little formal education in the lower social class, who happen to be among the most marginalized. Because it is related to oppressive cultural norms emphasizing patriarchal authority and harmony among family at the expense of women, this syndrome is brought about by a long-term, partial, and incomplete suppression of expressing an innermost anger.

It has been argued that hwabyeong’s etiology is deeply related to oppressive gender system. Consider a typical case of a 49-year-old housewife whose self-diagnosis is hwabyeong:

The reason for her anger was her family situation… To keep peace in the family, the patient had to suppress her anger and hide her hatred toward her husband and mother-in-law; she obeyed her husband and his mother. . . . However, she said she did not feel depressed and had never thought about suicide. . . . She attempted to avoid being isolated from her fellow workers since she believed they might think of her as a “good” person. She revealed her painful past memory of how she had been discriminated by her mother for being a daughter. Finally, her mother’s favoritism to sons and her gender discrimination did not allow the patient to complete her middle school education. (Min 2013, 55)

In short, hwabyeong is closely related to oppressive social environments. I will return to this point later in the next section.

V. Cross-Cultural Anger in Anger Disorder

In the previous section, I have provided a definition of hwabyeong as CBS. But it would be argued that anger may not be so culturally specific and distinctive, at least in the case of hwabyeong. Indeed, hwabyeong as CBS was deleted in DSM-V in 2013. More precisely, when the terminology of 25 types of CBS was explicitly replaced by nine types of “cultural concepts of disease”⁹ and hwabyeong was not included in the latest version of DSM.

In this section, I would like to conclude by examining the concept of culture in anger disorder as a culture bound syndrome. What is a role of culture in hwabyeong as culture bound syndrome? As Flanagan says, note that anger is a culturally malleable and socially constructed concept, in other words, “a cultured passion, a participant in modern normative orders, governed by complex psychosocial norms that provide scripts and permissions for what appropriately triggers anger, what warrants it, and what behaviors are acceptable when angry” (2018, xii). Should we talk about cultural relativism at some levels in considering anger? For instance, “Whereas German mothers tend to meet anger of children with their own anger, Japanese mothers meet children’s anger with disappointment and sadness” (Flanagan 2018, xiv)

However, it is not at all clear if hwabyeong is really a culturally specific, exotic, and unique mental illness. As far as the basic assumption behind CBS seems WEIRD-centric, calling hwabyeong culture-bound may imply that it is deeply irrational and scientifically primitive from the Euro-American perspective. But hwabyeong should not be seen as exotica in the museum of mental disorder. Conversely and ironically, the fact that some Koreans attempt to promote that hwabyeong is a uniquely Korean thing may be an internalized or reverse way of colonial thinking: “the project of defining a uniquely Korean malady reflects a desire among medical professionals to make the indigenous meaningful, thereby guaranteeing a tool for gaining circulation and foreign recognition. . . . The Korean distinction as analytical unit was favorably employed at first, only tentatively used, and then erased from the discourse” (Suh 2013, 100–101).¹⁰ As the therapy and research on hwabyeong develops, hwabyeong’s cultural uniqueness actually gets diluted. Paradoxically, efforts to globalize hwabyeong end up erasing its indigenous aspects. We find a similar movement in Min’s works: “Beginning with a passion to articulate the culture-bound attributes of hwa-byung [hwabyeong] in the early 1980s, Min ended up with a culture-neutral conceptualization of hwa-byung [hwabyeong] in the twenty-first century” (Suh 2013, 89).

After examining Min and others’ works, Soyoung Suh concludes, “what medical research about hwa-byung [hwabyeong] tells us is that there are no essentially Korean features of the mental disorder. Rather, medical professionals’ reports on Koreanness illustrate the process through which a biography of the local has emerged and been modified, disclosing its (dis)juncture with global trends” (Suh 2013, 95–96). While largely agreeing with her view, I am not denying the existence of hwabyeong once and for all. Even if hwabyeong is only found in Korea, this fact would not mean that it is a faked illusion. Insofar as it has relevant physiological mechanisms, hwabyeong can be considered a genuine mental disorder.¹¹ That is, it may involve some innate and universal machinery that produces anxiety and anger, which is embedded in a range of different cultures’ norms. In other words, hwabyeong as anger disorder can be universal given the universality of cultural factors for it.

In a similar vein, it may be plausible to think that hwabyeong is a variant of an existing universally occurring disorder, rather than a culturally distinct disorder, as far as hwabyeong can occur wherever similar cultural pressures of suppressing anger. In this way, ironically, a phrase made famous in the 1990s in South Korea, “what is most Korean is most global” is actualized.¹² I think hwabyeong may be universal if it refers to certain culturally specific idioms of distress. Indeed, there are similar descriptions and reports of hwabyeong as anger disorder such as irritability, aggressive disorder, dysfunctional anger, and anger attack elsewhere in the world (Min 2009, 19).¹³ If so, it is very dubitable that hwabyeong is really a culturally bounded syndrome to the extent that it results from “the imbalance between reality and anger,” which is in some sense pervasive in human life. As Lorde says in a different context, it is notable that “every woman has a well-stocked arsenal of anger potentially useful against those oppressions . . . which brought that anger into being” (1984, 127, my emphasis). If she is right about the quantifier (“every”), there may be not so culturally specific things about women’s anger.

Min and others point out that the collective emotion of han is deeply related to the causal mechanism of hwabyeong. It is assumed that han as the collective emotion is alive and well today. However, it is not clear if han has been actually and successfully transmitted from generation to generation in Korea. When talking about hwabyeong as CBS, han seems to suggest a sort of Korean exceptionalism of inherent and permanent sadness. Minsoo Kang, a professor of history, shows that the notion of han is deeply questionable given its troubling origin and meanings: “the idea itself has roots in the Japanese imperial ideology that was used to justify the subjugation and exploitation of Koreans during the colonial era. . . . The idea has its roots in Western theories of racial essentialism that the Japanese adopted, adjusted, and then utilized for their own purpose” (Kang 2022). On this view, the idea of han along with Koreans’ inherent backwardness and essential sadness were simply constructed in the modern era for the sake of colonialism and racism. In turn, after the national liberation, this essentialist notion of han was ironically utilized by Korean (ethno-) nationalists who see han as admirable inner strength, considering it to be the absolutely unique thing to Koreans (Kang 2022). In Korean cultural psychiatry, there were some explicit campaigns that try to promote hwabyeong as a uniquely Korean disease since 1980s. These efforts significantly contributed to hwabyeong’s registration in DSM-IV.

In this regard, there seems to be a colonial origin in conceiving han as hwabyeong’s pivotal emotional part. Further, the colonial aspects of the idea of han are not just imperialist but also sexist. This is because the colonial subjects are

consistently feminized as weak, irrational, primitive, childlike and unintelligent, needing the strong and rational rule of their masculine imperial masters. Once the Japanese who espoused the idea left the peninsula and Koreans adopted the notion that their people were defined by han, the concept was literally feminized through the idea that women were the exemplary carriers. This was expressed in the aesthetization of women’s sorrow. (Kang 2022)

Here we find a sort of double gendering in the case of han. That is, if Koreans are inherently feminine, then Korean women are feminine par excellence. While women are lauded due to their passivity and docility, they are naturally to be punished and disparaged when they try to assert themselves.¹⁴

According to Kang, however, this kind of praising women’s subordination is inappropriate in today’s South Korea given that women have better opportunities and access to education and work. Surely, one might argue that gender discrimination is not the only factor in hwabyeong because uneducated and poor men can have hwabyeong too. However, the social progress such as economic growth and democratization is not just limited to the domain of gender:

The idea of han has undergone a significant decline in cultural importance in South Korea itself since the late 1990s, now to the point of irrelevance. With the achievement of prosperity and democracy, the notion of an essential character defined by a profound sorrow from trauma and unrealized potential no longer seems appropriate. (Kang 2022)

Therefore, it would be a mistake to use the retrospective idea of han to define the culture of contemporary Koreans. Just as we cannot reasonably stick to the broad stroke notion of “Western individualism” to understand the people in the US, han as a sort of Koreanness may be too generic to explain the uniquely Korean culture, if any. As Kang convincingly argues, “intense emotionality is hardly unique to Korean narratives, and the notion of a specific kind of sorrow/regret/frustration/rage that only Koreans can feel is absurd” (Kang 2022).

Along with han, it is argued that collectivism in Korean culture is another important factor in the etiology of hwabyeong.¹⁵ According to Min, the importance of “we” relationships is expressed in the Korean culture of harmonious, family-oriented, interdependent collectivism. In this “we” culture, one tries to control oneself to not be aggressive to others. Suppression and endurance are virtues. Hwabyung [hwabyeong] seems to be the result of an effort by a victim not to jeopardize a “we” relationship with others. Therefore, it is natural that hwabyung [hwabyeong] frequently develops under the pressure of a socially relatedness like marriage (between wife and husband or mother-in-law) rather than blood-related family (Min 2009, 17). Similarly, he writes about a Confucian root of the patriarchal authoritarianism:

Traditional philosophies including Confucianism and the traditional patriarchal authoritative culture have supported the development of unique familial collectivism in Korea. In this culture, fathers, teachers, and kings are identified to be in the same authority [gunsabu ilche 君師父一體]. People have been taught to suppress anger and not to jeopardize social or familial harmony with those authority figures, engendering a suppression of anger. These traditional cultures have also been supportive in the development of gender discrimination and social class-related oppression, which has contributed to the social unfairness for women and lower-class people in their sociopolitical life. (Min 2013, 57)

Even though it is said that the idea of gunsabu ilche was predominantly applied to educated men, it can be arguably seen as a patriarchal embodiment of the traditional familial collectivism. Furthermore, it might be argued that there are other patriarchal elements in Confucianism. For instance, to name a few, the idea of patrilineage, female infanticide, wifely fidelity, and concubinage seem to constitute Confucian misogyny. If it is the case that Confucianism is deeply implicated with patriarchial social norms, Korean culture may be causally relevant to the etiology of hwabyeong. Although it is debatable if this diagnosis of Korean culture and Confucianism as its essence is entirely plausible, it seems that those traditional philosophies are losing their overall influences.¹⁶ Instead, I would like to suggest that in today’s multicultural settings it gets harder to do cultural psychology of hwabyeong’s unique Koreanness. Rather, even if it is the case that social codes such as suppression and control in “the traditionally familial, collective, and Confucian culture of Korea” (Min 2009, 13) were a main causal factor of generating the social conditions for hwabyeong, they have been significantly weakened. Arguably, traditional forms of han are considerably overcome by educational fever, rapid economic growths, and achieving democratic and egalitarian culture and ensuring human rights to certain degree.¹⁷ Along with globalization and multicultural interaction through the media and migration, deep structural transformations in family, civil society, and the state have produced more individualist culture. Further, various gender asymmetry and inequality have been challenged as well. For instance, despite backlashes, recent feminist movements like #MeToo have been very influential in younger generation in South Korea. For many younger generations, suppressing anger is not the only viable option like older generations. In this respect, talking about hwabyeong seems anachronic to some degree.

Surely, on the flip side, fierce competition and fast economic development can be another problematic source for anger, alienation, and extreme stress. In this respect, one may question whether there is an established sense of social progress. For it is hard to deny that today’s people are angry in most of times. While it is certainly a bad thing that we live in an age of anger, my point is that suppressing anger may be worse. In fact, it could be that releasing anger may be nothing more than the sufferer of anger venting out their anger. We may evaluate whether releasing anger is more fitting or not if the unfair event is redressed. My point is that proper ways of releasing anger can be healthy and politically useful. Given these considerations, the fact of social progress in culture shows that what makes CBS CBS is historical. CBS should not be seen as static and unchanging entities. Therefore, it is worth recalling that one of Ian Hacking’s points in the earlier section is that the socially constructed category of mental illness suggests its changeability, historicity, and instability (Hacking 1999, 6). If this is the case, we should be cautious not to prematurely reify the current categories of mental disorders.

Therefore, “we should avoid the assumption that the Western variants of disorders are somehow ‘purer’ and ‘less culture-bound’ than those that occur in other cultures” (Cooper 2010, 329). While maintaining that mental disorder is naturalistic, the closer attention to culture may elucidate the need to address social and cultural injustice or discriminatory treatment. That is, diverse ways to change oppressive culture through social movement can be correlated to the change of the diagnosis and treatment of mental disorder. In the case of hwabyeong, understanding and changing gender oppression and patriarchic culture is crucial to diagnose and remedy it.

Acknowledgments

This work was supported by the Ministry of Education of the Republic of Korea and the National Research Foundation of Korea (NRF-2021S1A5C2A02089018).

I would like to thank an anonymous reviewer for helpful comments and questions. An earlier version of this paper was presented at “Contemporary Moral Psychology and Cross-cultural Moral Psychology,” held at Georgetown University on September 22–23, 2022.

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