Hikikomori: Finding The Right Treatment For A Hikikomori
Hikikomori - A Tragedy Of Two Generations
An introduction into the Hikikomori problem in Japan best begins with a case study.
Hikikomori literally in Japanese means 'recluse' and is officially defined by the Japanese Department of Health, Labour and Welfare as "those people who have socially withdrawn from society for six months or more".
To understand to gravity of the Hikikomori problem in Japan, let us begin with the one of the most gruesome 'Hikikomori-triggered' crimes in Japan over the last decade, famously dubbed as the 'H-case'.
H, an ordinary old schoolboy, who was described as polite and smart by his teachers before he was labelled as a Hikikomorian, hijacked a bus and stabbed the passengers.
At just 17 years old, H was labelled as a Hikikomorian by the court and sentenced to six years for murder, hijack and other accounts of grievous violence offences described as 'Hikikomori-triggered' crimes.
On May 2000, H hijacked a bus and forced the driver into a 19-hour expressway odyssey stabbing a passenger to death. Although the media has widely reported this case as a Hikikomori-triggered crime, the real reasons and the administrative failures that pushed H to his limits were not made to public knowledge.
In the Hiroshima District Court, H was described by all those whom know him as a mild tempered boy who was a good student and an involved community member. H's parents recounted the "change" in their son's behavior after on day when he had performed badly in his exams and began to withdraw from the outside world. After numerous failed attempts to persuade their son out of his bedroom, H's parents sought help from youth welfare centers and mental health professionals, but they were provided with little assistance by the institutions.
Six years later, they still regret accepting the physician's diagnosis of their son as mentally ill and requiring full hospitalization. At first the family was reluctant to consent as H fiercely resisted to the idea of going to a mental hospital and they preferred to wait for and other diagnosis. However, they conceded when the physician said, "If you wait, I am still obliged to alert the health authorities about your son's mental condition. If the authorities may decide it is necessary to hospitalize your son, then others may find out about your son's Hikikomori behaviors. "
During the trial hearing, H claimed temporary insanity as result of the combination of the psychotherapy he had undergone, his vulnerable age and his social withdrawal. However, what was disturbing as the facts of the case unfold was that H was subjected to shock-therapy and a number of anti-depressant drugs without knowledge form his parents. This was the case even when his mother directly asked about the kind of medication given to her son. H also admits to having committed the crime as an act of retaliation against "voluntary hospitalization" by his parents, as well as to protest against the physicians that have labeled him as mentally ill.
What is Hikikomori and its controversial definition?
Hikikomori was brought abruptly into public awareness by psychologist Tamaki Saito and through popular media outlets in recent years, as a Japanese phenomenon of acute social withdrawals quickly spreading among Japanese youth. Colourful definitions of Hikikomori flourished and have been largely associated with negative stories of juvenile lunacy and violence. In attempting to control the public controversy and Hikikomori hysteria, the Ministerial of Health, Labour and Welfare acted to officially define Hikikomori as "those people who have socially withdrawn from society for six months or more" . Despite the vagueness of this official label, it legitimately recognised that reclusive youth who refused to participate in socially established norms was a social problem, and by so doing, increased the controversial nature of Hikikomori.
The public discourse on and bureaucratic reactions to Hikikomori exposes a whole range of cultural, social and economical problems in Japan, as well as its opaque practices in the institutional and political process. However, in-depth analyses of all these issues are beyond the scope of this article.
Finding the Right Treatment Towards Hikikomori?
H’s story represents the conflicts buffeting Hikikomorian families and the Japanese mental health providers. In an already strained public health system, a Hikikomorian must first be diagnosed as mentally ill or retarded to receive professional treatment, and there are few alternative courses of action available where he or she refuses to carry the mentally ill label.
In keeping with the traditional paternalistic approach, as controlled by the Ministry of Health, Welfare and Labour (MHWL) and the Psychiatric Review Board (PRB), the designed physicians follow a cloaked code of practice involving little participation from the patients or their families.
The physicians, operating under the guidelines of the Ministry of Health or the Local Council for Mental Health, have avoided mentioning “Hikikomori” in their diagnosis and generally preferred to label it under other mental disorders. This course of action by the physicians has been justified as an elaborate attempt to protect those dealing with Hikikomori from the negative social stigma attached to the condition.
In reality it does the very opposite by entrenching the belief that being mentally ill is far more socially acceptable than being a Hikikomorian. Having been pressured by this institutional and social framework against Hikikomori, and having entrusted the welfare of their son in the hands of the hospital, H’s parents were overwhelmingly disappointed with the hospital’s failure to protect their son and to caution them about the range of psycho-therapy drugs administered to their son. H’s parents now are demanding answers from the hospital and have considered filing a suit against the physicians. Their plight has inspired them to establish a self-help association for hikikomorian parents. They also have utilized the media raising public awareness of hikikomori as more than a private family matter but as a problem pressing against Japan’s rudimentary welfare system.
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Treatment of Hikikomori Under Japan's Mental Health Act 2000
The H case casts doubts over the notion of "voluntary hospitalization", recently enacted under the Mental Health Act 2000 , whereby a Hikikomorian family would customarily submitted to the physician's acts on blind faith, without even questioning the subsequent treatment that follows. This further raises the issue of choice and questions the degree of care and diligence exercised by Japanese mental health providers over patients under their care.
Shame Culture and Concealing Diagnosis of Hikikomori
To protect Hikikomori suffers and their families from the social stigma attached to this condition, the diagnostic practice of cloaking Hikikomori under other recognised psychological illnesses has been a known practice in Japanese hospitals. This diagnostic practice is encouraged by the hospital as being 'kind', in that it provide a psychological escape route for the patient's family from the shame attached to Hikikomori. As such many different mental disorder names has been used to cloak Hikikomori. Prognosis labels ranging from minor mental disorders such as "clinical depression", "agoraphobia" or "acute social withdrawal", to extreme cases of "acute schizophrenia" and neurosis abnormalities, are all commonly used and vagueness is considered a virtue.
The extent and nature of professional manipulation of mental disease names to conceal the condition of Hikikomori reflects the degree of the social stigmatism attached to the label . Increasingly, Hikikomori sufferers and their families are being associated with the term "katawa" by the Japanese society, which is a discriminatory term that describes handicapped and mentally retarded people. Thus families dealing with Hikikomori often may go to extraordinary lengths to keep the condition hidden so as to protect their family's reputation . This social environment has been the main justification for physicians in employing their manipulative method of diagnosis of Hikikomori, in which misleading the patient is necessary to protect his personal and family interests .
According to Doctor Tamaki Saito, whom first coined the term Hikikomori and runs the outpatient clinic at Sasaki Hospital in Chiba Prefecture, it is sufficient to simply inform the patient of any name of the disease, for the purpose of categorisation. While Doctor Saito avoids describing hikikomori as a mental illness, he readily treats suffers through traditional psychiatric methods such as hospitalisation, psychotherapy and counselling. However, this customary practice of diagnosis worsens the social stigma attached to Hikikomorians and enhance the false belief that it is more socially acceptable to be mentally ill than a Hikikomorian.
Professional supremacy further protracts the confused and misleading images of Hikikomori available to the public. In 1998 Saito wrote that "regardless of the patient's will, social withdrawal must be treated medically" . Other mental health professionals, who prefer traditional institutional treatment of recluses and consider themselves to be experts on Hikikomori problems hold that Hikikomori is a serious psychopathic sickness on a society wide scale.
Curiously , Saito was a student of Inamura Hiroshi, a well known psychologist in the 1980s who purportedly identified a new mental disorder that he termed "Apathy Syndrome" or "tokokyohi", the school refusal phenomenon in Japan. Inamura's treatment for Apathy Syndrome started in 1981 with the committal of teenage tokoyohi to mental wards of hospitals where Inamura had nearly 5000 teenagers "locked away, forced-fed tranquilizers and isolated form their parents for weeks at a stretch - all to 'cure' truancy". Inamura was eventually forced to abandon his aggressive treatments by critics from the mental health profession and the media at the time. Despite this, Saito's research on the Hikikomori issue and his treatment philosophies still refers to his mentor's work. Saitor performs psychotherapy for his Hikikomori patients regularly in Sasaki Hospital and claims to provide a cure rate of 30 percent .
One interesting justification for why Japanese doctors conceal their diagnosis of Hikikomori can be found in the notion of "amae", which was described by Takeo Doi in his classic "The Anatomy of Dependence" as dependency arising form the infant's passive love of his mother as a key psychological bond with the Japanese family and within members of groups in adult society. A weaker person within the social unit may presume upon a stronger for care and assistance, and the stronger will indulge the weaker, permitting and encouraging a dependent relationship. In the case of Hikikomori or other serious mental illness, this social environment of dependence justifies the need to protect patients from the stigma attached to his/her condition and a new social grouping. The culturally related vulnerability of the patient empowers the doctor to control the social and medical environment of the patient, by assuming the stronger person's role to normalise the weaker person. However, these generalised cultural conceptions only provide a limited means of explanation given that such culturally motivated practices may be found elsewhere in the world.
Hikikomori and Japanese Mental Health Care System
Statistics over the past decade paint a dreary image of the state of Japan's mental health. Japan has the highest number of hospital patients with mental illness in the world and its ratio of beds and admissions into psychiatric hospitals to total population has been growing at an alarming rate [8-10].
Long-term institutionalization has been the primary treatment for mentally ill patients in Japan since the early 1920s. The average length of stay in a Japanese mental hospital in two decades was 41 times the average stays of patients in the United States. Although the government states that this figure has dropped in recent years due to reforms, Japan still has one of longest average hospitalization period in the world. Some aspects of the reformed Japanese mental health care system, such as consent based hospitalization, community integration programs and a more localized Psychiatric Review Board, undoubtedly have contributed to the improved figures, though other social factors such as wider social acceptance, privatization, a more mental health-conscious workforce and work safety laws, and the growing number of public interest groups lobbying for better treatment of mentally ill patients probably have had greater impact.
Although the government has encouraged and supported the integration of mentally ill people in the community and the development of rehabilitation programs since enactment of the Mental Health Law of 1988, implementation of such programs has been slow . Improvement in Japan's mental health system has not been enough for people suffering from mental disturbances, as recent studies suggest that the majority of Japanese population carrying psychiatric disorders have not been able to access mental health care or other support systems.
However, there have been increasing doubts, within the health care system itself and in society at large, over fundamental questions concerning the future of the state of Japan's mental health. Surging public dissatisfaction with the problems in Japan's mental health care, in particular the growing number of new juvenile psychiatric disorders and the epidemic proportion of Japanese youth demonstrating anti-social or Hikikomori-afflicted behaviors, are forcing a reassessment of the current practices long held and deeply rooted in Japan's mental health care system. It is only in recent years that the Japanese government has started to place emphasis on the treatment of mental patients and made efforts to address the issue of public choice in its closed mental health care system.
Hikikomori and the Media
The media's role in bringing these Hikikomori-related issues to public attention serves as a double edged sword for Hikikomori support groups. Whilst Hikikomori is making headlines across news, popular television programs, manga and best-selling books, generally it has been stereotyped in stories of homicidal Japanese teenagers and juvenile abnormalities, entrenching anti-Hikikomori attitudes in the readers. On the other hand, the media had a useful tool for Hikikomori interest groups to gain support for their campaigns and to shame the mental health institutions into action.
Scandals within the mental health profession and cases of negligent treatment of Hikikomori suffers has undercut the public faith in the conventional psychiatric practice traditionally held. Physicians are exclusively designated by the bureaucracy: neither is there any public review mechanism such as enforceable disclosure and negligence proceedings, nor internal policy review systems such as patient custody standards and explicit codes of ethical reporting in Japanese mental health system.
Hikikomori and Japan's Patient's Right Movement
The momentum from Japanese reformers campaigning for Patient Right Law and seeking to establish the principle of informed consent in Japanese medicine is slowly reaching the mental health arena. Visible signs of this can be observed from the internal fractions in the mental health profession, which has divided physicians who are fiercely resistant to changes to conventional treatments, from those who have been at the forefront of advocating for alternative practices that involve community and patient participation. Consequently, the mental health institution is now no longer immune to public criticisms over such issues as patients' rights and public choice. This is one of the many parallel benefits from the patients' right campaign in general Japanese health care that may be expected for mentally ill patients, such as the support of the bar association to the idea of informed consent before voluntary hospitalization comes into effect.
The meaning of "patient consent" and "voluntary hospitalization" is so ambiguous as to accommodate a diverse range of practices, ranging from second diagnosis and consultation before consent is validly granted where previously there had been none, to offering the patient a choice among thoroughly explained treatment alternatives.
A number of influential reports commissioned by the Ministry of Health investigating the state of Japan's mental health and, in particular, those issues related to Hikikomori has resulted in the Mental Health Act 2000. This legislation presents a marginal victory for both sides and its impact has yet to be seen in the current mental health edifice. While the Act recognises the principle of informed consent prior to hospitalisation, it stops short of codifying public accountability and review mechanisms, instead conferring more control upon local governments and PRB, and so professional supremacy remains intact.
Conclusion and Future Outlook
As Hikikomori suffers are by definition non-socially involved, their ability to challenge public discrimination and the health system is limited.
Nevertheless, the outlook for Hikikomori families in their struggles against discrimination is improving with growing local and international support from self-action groups, online-based networks, sociologists, the media and even some mental health professionals from traditional practice. By voicing their dissatisfactions with the current mental health facilities and by campaigning for greater public support, Hikikomorian groups have found ways to challenge the mental health system and to become an active social voice for Hikikomorian interests, reluctantly being recognised by the government. In particular, the current debate, over the definition of Hikikomori as a mental illness or the cultural, economical and institutional reasons for it, illustrates the customary practices and attitudes deeply rooted in the paternalistic Japanese mental health system and widely entrenched in the Japanese consciousness.
The dynamics and complexities of this public discourse is best illustrated in the key questions on the Hikikomori debate highlighted in the literature and the press that can be compiled as follows:
1. Is it appropriate for Japanese mental health professionals to medically label or "medicalise" an anti-social behaviour as a condition seriously deviant form the norm and thus requiring psychological treatment as well as institutionalised control?
2. Is it the traditional paternalistic approach by the Japanese government desirable or legitimate in controlling and regulating anti-social behaviour via its new reform to the mental health system under the principles of "voluntarily hospitalisation" and "normalisation"?
3. To what extent does the current concept of "informed consent" under Japanese mental health law protect the basic citizen and human rights of a Hikikomorian? What are the limits of prescriptive hospitalisation in terms of Hikikomorian rights?
4. What is the role of the community and education system in rehabilitation of anti-social behaviours?
5. Is Hikikomori a new phenomenon, or a new label for older social problem in Japanese culture such as tokokyohi (school refusal), or otakuzoku (obsessive anime and manga fans)?
6. Is it reasonable to attribute Hikikomori as a cultural malady unique to Japanese society or is this supposition perpetuation of the Nihonjin-ron myth of Japanese cultural uniqueness?
7. What role do media play in exacerbating the problem and prompting enthusiasm for the Hikikomori behaviour?
These questions demonstrate the controversial nature of the Hikikomori phenomenon. It continues to generate issues pertaining to the secrecy practice and shaming behavioural pattern of Japanese Hikikomori families, mental health professionals, the government and even the society at large, that cannot be sufficiently explained by models of economic behaviour and rational social factors.
For the growing number of families struggling to deal with Hikikomori, the answer is not easy to find but simply ignoring the problem will only exacerbate it in the long term, perhaps the question we must is why, what has driven your child to lock himself or herself up and withdraw from the rest of the world? For some it might be bullying at school, whilst for others it is the fear of failure or it might be the stress of Japan's highly competitive examination system. Whatever the Hikikomori triggering-experience might be it must be found before you can begin to help someone with Hikikomori to trust the world again.
 Ministry of Health, Labour, and Welfare 'Annual Report on Health and Welfare 2009-2010' and 'Special Report of the Department of Health and Welfare -Persons with Disabilities Aiming at the Independence and Social Participation of the Disabled'.
 See Articles 22-3 to 22-4, Law Related to Mental Health and Welfare of the Person with Mental Disorder 2000, 'thereafter the Mental Health Act 2000'.
 Itou, J. "Shkaiteki Hikikomori Wo Meguru Tiki Seisin Hoken Katudou No Guideline - Mental Health Activities in Communities for Social Withdrawal" Tokyo: Ministry of Health, Labour and Welfare 2010.
 Tatsushi, O "Managing Categorization and Social Withdrawal" (2004) 13 International Journal of Japanese Sociology 120.
 Katagiri, M. 'Jiko to Katari No Syakaigaki : Sociology of Self and Narrative' 2000.
 Saito,T. 'Shakaiteki Hikikomori' Tokyo: PHP kenkyuujyo 1998.
 Nobuhiko Kuramoto, "The States of Hikikomori in Its Three Periods" 2005 and White. M 'Taking Note of Teen Culture in Japan: Dear Dairy, Dear Fieldworker -Doing Fieldwork in Japan' Honolulu: University of Hawaii Press, 2003.
 Naganuma Y. et al, 'Twelve-month use of mental health services in four areas in Japan: Findings from the World Mental Health Japan Survey 2002-2003', 2006 (60)2 Psychiatry and Clinical Neurosciences 240.
 Matsubara et al, 'Mental Health in Japan -Psychiatric Care Still Mired in Dark Ages' The Japan Times, Two-day series, Sept. 12, 2001.
 Koizuma, & Harris, 'Mental health care in Japan', 1992 (43) Hospital and Community Psychiatry 1100.
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