By Edd GentFeatures correspondent
Maika ElanSocial isolation is often blamed on technology, but could it be part of the solution?
(This article is illustrated with a series of portraits by photographer Maika Elan.)
In today’s connected world it can feel difficult to disengage. An endless stream of emails, posts, tweets, likes, comments and pictures keeps us constantly plugged into modern life.
But in Japan half a million people live as modern-day hermits. They are known as hikikomori – recluses who withdraw from all social contact and often don’t leave their houses for years at a time. A government survey found roughly 541,000 (1.57% of the population) but many experts believe the total is much higher as it can take years before they seek help.
The condition was initially thought to be unique to Japan, but in recent years cases have appeared across the world. In neighbouring South Korea, a 2005 analysis estimated there were 33,000 socially withdrawn adolescents (0.3% of the population) and in Hong Kong a 2014 survey pegged the figure at 1.9%. It’s not just in Asia, cases are appearing in the US, Spain, Italy, France and elsewhere.
Whether due to increased awareness or a growing problem remains unclear, but concern around social isolation is on the rise globally. Last January the UK appointed its first minister for loneliness and recent Office of National Statistics data found nearly 10% of 16 to 24-year-olds reported feeling "always or often" lonely.
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A controversial but common theme in hikikomori research is the isolating influence of modern technology. Any potential links are far from settled, but there’s concern Japan’s lost generation could be a canary in the coal mine for our increasingly disconnected societies. At the same time there’s hope technology could help bring people back from the brink.
Maika ElanHikikomori often feel isolated due to the great expectations placed on them in education and the workplace (Credit: Maika Elan)The term hikikomori, often used interchangeably for the condition and its sufferers, was coined by Japanese psychologist Tamaki Saitō in his 1998 book Social Withdrawal – Adolescence Without End. Today the most common criteria is a combination of physical isolation, social avoidance and psychological distress that lasts six months or longer.
The condition was originally considered “culture-bound” and there are reasons to think Japanese society is particularly vulnerable, says Takahiro Kato, an associate professor of psychiatry at Kyushu University in Fukuoka, who both studies and treats hikikomori.
“In Japanese there’s a very famous saying, ‘A protruding nail will be hammered down’,” says Kato. Only half-jokingly, the 6ft 2in doctor adds that’s why he walks around with a slight hunch so he’s not seen as arrogant. Rigid social norms, high expectations from parents and a culture of shame make Japanese society a fertile breeding ground for feelings of inadequacy and a desire to keep one’s head below the parapet, Kato says.
After quitting his job in 2015, Tomoki, 29, tells me he was determined to get back into work and regularly visited the job centre. He also attended a religious group almost daily, but the group’s leader started publicly criticising his attitude and inability to get back into work. When he stopped attending the leader called him several times a week and the pressure, combined with that from his family, eventually caused him to withdraw completely. (The names of all hikikomori have been changed to protect their identity.)
“I blamed myself,” he said. “I didn't want to see anyone, I didn't want to go outside.”
School is a monoculture, everyone has to have the same opinion. If someone says something they're out of the group - IchikaAt Fukuoka city’s hikikomori support centre the Yokayoka Room – “take it easy” room in the local dialect – one by one the group describes the pressure they felt to conform. “School is a monoculture, everyone has to have the same opinion,” says one of the visitors, Haru, 34. “If someone says something they're out of the group.”
Living up to the expectations of Japanese society has also got harder. Economic stagnation and globalisation is bringing Japan’s collectivist and hierarchical traditions into conflict with a more individualistic and competitive Western worldview, says Kato. And while British parents might give short shrift to a child refusing to leave their room, Japanese parents feel a strong obligation to support children no matter what and shame often prevents them from seeking help, says Kato.
But the increasing number of cases outside Japan is leading people to question the culture-bound nature of the condition. In a 2015 study, Kato and collaborators in the US, South Korea and India found cases matching the clinical criteria in all four countries.
Maika ElanIn this portrait by Maika Elan, we see Ikuo Nakamura, 34, a hikikomori who had locked himself in his room for seven years (Credit: Maika Elan)Lead author Alan Teo, an associate professor of psychiatry at Oregon Health and Science University in the US, says he is regularly contacted by Americans self-identifying with the condition.
“People have this underlying assumption it must be most common in Japan,” he says. “If you formally measured how common it is we might come up with some surprising information.”
Spanish psychiatrist Angeles Malagon-Amor, at Hospital del Mar in Barcelona, stumbled across the problem during a home treatment program in Barcelona. Malagon-Amor and colleagues frequently found patients with extended periods of social withdrawal, which led her to the literature on Japan’s hikikomori. Between 2008 and 2014 they came across 190 cases – the most recent data they hold – but that was before the program was expanded and she’s sure it’s the tip of the iceberg.
“At the time, we were two psychiatrists and two nurses for a population of more than one million,” she says. “I think there must be a lot more cases.”
Establishing a broader explanation is fraught with difficulties though.
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“One of the reasons hikikomori is fascinating is that there's not one explanation,” says Teo. “It's a lot of factors coming together.”
One factor regularly discussed is the role of technology like the Internet, social media and videogames – already the source of contentious debate in mental health research. Many hikikomori I spoke to were prolific internet and videogame users and multiple studies have noted high levels of technology use, but it’s far from universal and the nature of the relationship is still unclear.
In South Korea, anyone who remains isolated for at least three months is termed “oiettolie”, the link is more established. A 2013 study of 43 oiettolie found that nearly one in ten were already considered to be addicted to the internet, and more than 50% were thought to be at high-risk of internet addiction.
TaeYoung Choi, a psychiatrist and researcher at the Catholic University of Daegu who worked on the study, doesn’t think technology necessarily causes withdrawal, but he thinks it can support and deepen it. “Some people can get more isolated by using technology, which makes that isolation more rigid and more severe,” he says.
Maika ElanInternet addiction is sometimes blamed for the hikikomori's isolation, but some experts hope that it could help their rehabilitation too (Credit: Maika Elan)In a 2018 study of hikikomori cases In Barcelona, Malagon-Amor said they found only 30% exhibited internet addiction. But they found that group tended to be younger – the average age across all 190 cases was 39 but it was just 24 for those addicted to the internet.
“For what we've seen now, it’s not that big an issue,” she says. “But I think this is going to be much bigger in the next few years in those cases of social isolation in young people with Internet addiction.”
The effect of technology could also be more subtle, says Kato. Computer games have rewritten the nature of play, he says, with children spending ever more time in controlled virtual environments rather than the unpredictable real world. At the same time the internet, smartphones and social media have made indirect rather than face-to-face contact much more common.
“Now society has no risk, no direct communication,” says Kato. “It’s easy to hit the reset button and reverse and there's low experience of failure.” He thinks that’s detrimental to children’s development, making them less resilient and less adept at interpersonal relationships. Just like you need to be exposed to dirt to develop immunity to diseases you need to be exposed to risk and failure to develop resilience and independence, he adds.
At the Yokayoka Room patients said they say they feel more able to speak freely on the Internet. When I ask why they say it’s the anonymity it provides. Ichika, 27, adds that he likes the ability to always interact on his own terms.
There is some recognition of the limitations of this kind of communication. Hinata, 32, worries about the superficial nature of online dialogue and the ease with which you can avoid conflict. “We always try to make friends with the people who have the same opinion where we can feel more comfortable to comment,” he says.
“Technology itself can’t be 100% behind the aggravation of hikikomori as a world phenomenon,” says Choi. But he thinks our increasing ability to shop, play and socialise without real-world interactions could be exacerbating social isolation.
Face-to-face contact, either in person or on video-chat, corresponds to lower risk of depression, compared with contact by phone, email and social mediaThere’s simply not enough research to draw any conclusive links yet, says Teo. But he says it does chime with his gut feeling, which is based partly on research outside the hikikomori field. In multiple studies his lab has found face-to-face contact either in person or on video-chat corresponds to lower risk of depression, compared with contact by phone, email and social media.
“If interactions online become a substitute for face-to-face interactions, I think the research that I've done and other folks have done indicate that that's problematic,” he says.
Lines of communication
It’s important not to demonise technology though, says Teo. Social media or email are not the underlying causes of mental health problems, they are vehicles for communication that can be used both positively and negatively.
In particular, the internet provides a window into the isolated lives of hikikomori. Last year Teo and researchers in China used social media apps like WeChat and Weibo to survey socially withdrawn teenagers. It cost just $7.27 (£5.53) per participant to reach 137 people, one-fifth of whom were experiencing some level of social withdrawal, suggesting it could be a cost-effective method for reaching hidden cases.
The growing interconnectedness of online and offline worlds could also offer ways to ease hikikomori back into everyday life. In 2016 Kato published a case report on a patient who suddenly started going out daily after downloading Nintendo’s hit smartphone game Pokemon Go.
The game uses augmented reality to overlay digital creatures onto the real-world that players have to roam about collecting. Kato thinks this kind of bridge between real and virtual worlds could help encourage hikikomori out of their homes and even make it easier for health workers to make first contact, particularly if it can be tailored to their needs. For example, says Kato, this kind of game could be tweaked so valuable items appear at hikikomori support centres.
He’s also started working with a Japanese company to create a robot that could reintroduce hikikomori to social contact in a controllable way. Researchers in Hong Kong have successfully used dogs for a similar purpose, which he thinks could serve as a template. "But Japanese like robots!" he adds.
Maika ElanIn this portrait we see Riki Cook, who is American-Japanese and lives alone in Chiba, Japan (Credit: Maika Elan)There may also be less hi-tech ways to exploit hikikomori’s relationship with technology. Shinichiro Matsuguma, a PhD student at Keio University School of Medicine in Tokyo who specializes in positive psychology, has set up a non-profit to rehabilitate hikikomori called the Strength Association. He’s provided coaching to 32 patients using principles from positive psychology, which focuses on strengths rather than flaws. The majority of his clients play videogames so this typically involves discussing playing styles and motivations to identify strengths like teamwork, strategy or leadership.
"Many people, even their parents, see hikikomori as not doing anything,” he says. "But from my perspective, they're developing their strengths through the video games. And I always tell them while you're playing video games you are developing strengths that can be applicable to different life domains."
Establishing these strengths improves self-esteem, he says, but can also guide patients on the best path to re-entering society. The approach has yet to be scientifically evaluated, but he says almost 80% have taken a first step towards reintegration like going back to school, university or vocational training.
Remote counselling
Experts agree though that there's no substitute for direct social contact and intensive therapy. Yoko Honda, a clinical psychiatrist who manages the Fukuoka City Mental Health and Welfare Centre, says the national government has been pushing them to use social media to provide remote counselling to hikikomori, but they’ve resisted.
“Just one tweet is not enough for expressing our anxiety or emotions,” she says, though she agrees it might be useful for reaching new patients.
Asides from psychotherapy and medication to treat any underlying psychiatric disorders, a central plank of their strategy is family training to fix dysfunctional home environments. The Yokayoka Room also provides a safe haven for those on the path to recovery to meet others like them and relearn atrophied social skills. But she says the varied nature of cases makes treating them tough.
“We hope to give tailormade support to all these hikikomori,” she says. “But we always need a lot of labour, a lot of time.”
That’s something Malagon-Amor found in her 12-month study of Barcelona’s hikikomori. Those who received more intensive therapy either at home or in hospital reacted best. Less intensive outpatient services were linked to higher abandonment of treatment and often worsening isolation. “They're very fragile patients,” she says.
Whether or not the West should be gearing up for a tsunami of such patients is still unclear. But social isolation can be a feature of other conditions, from depression to PTSD, so Malagon-Amor thinks the West can learn a lot from the Japanese experience.
And regardless of the scale of the phenomenon, Teo hopes hikikomori research will broaden our understanding of the importance of social connections to our mental and physical health.
“When I talk to parents of someone with hikikomori it's very clear to me that the social isolation is causing huge negative impacts – it ripples through the individual, to their family, to others,” he says.
“So that social impairment, problems with social connections, we haven't paid enough attention to that in medicine. And I think now with hikikomori, with more attention to loneliness we are finally starting to look at these issues as health issues. And that's good.”
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