1. Elderly hikikomori in underpopulated areas

In our country, there have been various surveys about hikikomori (the definition will be explained later) since around 2000. It was estimated by a 2010 Cabinet Office survey that there were 700,000 hikikomori in the whole country. There is some debate surrounding this figure, and family associations have claimed the number to be over one million based on their own surveys, but we can probably assume that the number given by the Cabinet Office survey is not too far from the reality.

Recently there have been many indications that the average age of hikikomori is increasing. Once someone becomes reclusive it is not easy to get back out into society, and it is considered that those who have been hikikomori for a long time are raising the average age. However, it has also been pointed out that there are people who become hikikomori when they get older (in their 40s and above), and I think that both of these factors are playing a part. Social withdrawal was previously thought to be a problem faced by young people and their families, but after a time the hikikomori issue has come to include older people living alone, and it has become necessary to reassess it as a regional problem.

Social withdrawal is certainly not only a problem for young people in urban areas. Fujisato Town in Akita Prefecture, a town famous for coming together to support hikikomori, is a municipality located at the foot of the Shirakami Sanchi with no railway or national highway passing through it. However out of a population of just over 4,000 people, apparently there were over 100 hikikomori. Almost half of the hikikomori are at least 40 years old. It is not hard to imagine that it can be extremely difficult to support older hikikomori in areas where the society has limited social resources.

2. Encounters with hikikomori during support operations following the Great East Japan Earthquake

Despite having come across the reports like these, it was very rare for me to meet hikikomori in my daily medical examinations, like many psychiatrists. Even when their families consulted with me, I did not often receive feedback that medical examinations had led to improvements in adjustment for the person in question. The turning point was the Great East Japan Earthquake.

On March 21 just after the earthquake had occurred, I came to Noda Village, within the jurisdiction of the Kuji Public Health Center in Iwate Prefecture, where I provided support as a psychiatrist in local mental health activities. When I entered the site and received the first briefing from the village nurses, the role expected of me as a psychiatrist was given as providing care for people who had lost their families, along with providing care to those who needed continuous psychiatric support because they were hospital outpatients and so on. Then on the next day after the activities started, between my rounds of the shelters, guided by a nurse I visited the homes of three men in the village for whom support had come to an impasse, despite them having been previously understood to be hikikomori. Under the exceptional circumstances of the great earthquake, visits by outside helpers had been accepted without too much discomfort. This was probably due to the keen insight of the nurses who had been involved for many years.

The details and backgrounds of the three cases differed, but as I continued my involvement with them through visits, after half a year, the man who had been withdrawn for the longest period of time started looking for work, and before long he got a steady job. Later the other two, under the medical care, also started slowly on the path back to society. Gradually I began to receive requests related to the support for hikikomori from people connected to mental health who had been following the series of developments. In particular I unexpectedly received requests for lectures and meetings with the families of hikikomori from Hirono, a town in the jurisdiction of the Kuji Public Health Center, where there had been relatively few disaster victims. The improvements of the three people were certainly not the result of my involvement, but rather were brought about by the exceptional circumstances of the earthquake. However, I think that in a sense the requests were made by people clutching at straws, due to their high level of concern and distress about the hikikomori problem.

3. The background to Hirono’s mental health activities

What people of local communities unanimously express is that the families of hikikomori tend to strongly conceal the fact, and that in this area where it is difficult to access information, even if the person or their family begins to search for a solution, they will often end up at a loss as to who to consult with and how to get help. It is extremely difficult to meet the needs of those requiring the most support simply by repeating general public information and waiting to be consulted, and there is a need for a proactive approach by those providing the support.

This area had once been counted as one of the municipalities with high frequency of suicides in Japan. To combat this, Iwate Medical University’s Doctor Kotaro Otsuka (currently a lecturer of the Neuropsychiatry Department at the same university) and others carried out active local intervention and continued steadily working to train attentive volunteers. As a result the ground was laid for local mental health, which produced the visible result of halving the suicide rate. The area is such that people will draw attention to a neighbor’s mental distress.

From 2012, I worked as a speaker in workshops about hikikomori three times only in Hirono. The majority of participants were welfare commissioners, people from the town’s independent healthcare promotion committee (one person is usually assigned to fifty households), and in addition, non-specialist volunteers with an awareness of the problems in the area.

4. Surveying the approximate number of hikikomori in Hirono

As stated earlier, the welfare commissioners in Hirono are carrying out their work extremely well. In 2014 they gathered information and surveyed the approximate number of those understood to be hikikomori in the areas assigned to each welfare commissioner.

Hikikomori is defined as those who avoid participation in society (work and association with people outside of the household) and continue to generally remain in their home for at least six months (this includes people who may go outside but do not associate with other people). In short, the survey does not question whether or not the person has a mental disability, and the subjects are taken from a wide age range of 16 to 64. I believe that this survey is suited to addressing the families’ acute concerns.

50 people were understood to be hikikomori, including those who had been identified through the town’s support institutions from before the survey. With 50 people out of a town of 15,000, we may have only been able to grasp a small part of the problem. However, listening to the survey report, I felt very impressed that the town had been able to come together to carry out a survey like this.

Breaking down the details of those 50 people, the proportion of older people was greater than I had imagined, with those over 40 accounting for 60% of the total. Furthermore, as for at what point they became hikikomori, 56% of people became hikikomori over 22 years old, and 34% became hikikomori over 31 years old, and it was thought that the majority had experienced working. This suggests that their strong inclination towards working and subsequent failures and setbacks related to working may have been the trigger for them to become reclusive. In fact, the majority of the hikikomori that I was able to speak with expressed a desire to work, and said that if they had the chance they would like to get a job.

5. The start of the town coming together to tackle the issue

Adopting the concept that creating a place to belong means creating roles, Fujisato Town in Akita Prefecture is placing great importance on providing opportunities for hikikomori to find work. Hirono, following this example, is also seeking to provide support using its rich primary industries. There may be situations in the town when literally any help is appreciated, such as harvesting of cultivated shiitake mushrooms and processing of kelp. In order to make use of these circumstances and secure opportunities for short-term or short-time work, they are just beginning to use veteran healthcare nurses’ connections to develop understanding workplace mentors. Furthermore, it has been recognized that, in order to support people looking for work, it is essential to have a coordinator who can connect the hikikomori to workplaces and be close by for on-the-job training, and there is a drive to train competent people who can undertake that kind of role. In addition, using the town’s facilities, preparations are currently being carried out to establish a salon for hikikomori, and the selection of someone to manage the salon is underway.

6. The role of psychiatrists

My own role in the town’s support of hikikomori was to provide assessments from a psychiatric point of view. So far I have carried out meetings with 26 hikikomori in the town (one part was with the families only). There were multiple people for whom medical support should have been a priority, such as people who had been suffering from drawn out depression, and those with developmental disabilities who had been bullied in their youth and had a fear of interacting with people, a result of psychological trauma. In addition, there were several people with intellectual disabilities that had gone unnoticed in a time when special needs education was lacking, and had been overlooked up until now.

Therefore, my understanding is that multi-layered support on medical, welfare, and psychiatric levels should be carried out, and that I first have to assess the subjects. I can generally make my rounds in Hirono for about 10 days a year. That role amounts to no more than a small part of the overall effort, but along with those who continue to enthusiastically participate in the effort with the motto of aiming for a community where everyone is welcome to live, I would like to carry on putting effort into providing support both for outreach activities, and for the support staff themselves. The support and the survey research go hand in hand. Helping to gain an in-depth understanding of the actual states of the hikikomori and verifying the effectiveness of the support measures are roles that I believe I am able to fulfill.

Mitsuru Yamashina
Professor, Faculty of Letters, Chuo University
Areas of Specialization: Psychiatry, Clinical Psychology

Mitsuru Yamashina was born in Aomori Prefecture in 1961.
He graduated from Niigata University School of Medicine in 1989.
After serving as a doctor at Tokyo Metropolitan Matsuzawa Hospital, an assistant and lecturer at Juntendo University Faculty of Medicine, and a professor of Bunkyo University Faculty of Human Sciences, he assumed his current position in 2010.
He holds a Ph.D. in Medicine (Juntendo University) and is a designated doctor of psychiatric healthcare and a clinical psychologist.
His specialist field is youth psychiatry and psychoanalytical psychotherapy. He aims to be an intermediary between clinical sites and psychology education, and is working on clinical research.
His written works include Integration of Psychoanalytical Development Theory 2 (co-supervisor of translation), Procedures for Psychoanalysis Diagnostic Interviews(co-authoring), and more.
From FY2016, he has been working on the research funded by the JSPS Grant-in-Aid for Scientific Research (KAKENHI), Proposals for Comprehensive Support Measures, Based on the Key Pillars of Regional Intervention and an Understanding of the State of Older Hikikomori in Underpopulated Areas (project number 16K10258).