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Shinichiro Matsuguma

Applying Strengths from the Virtual to the Real World:
Strength Intervention for Hikikomori Youth: A Case Study

Shinichiro Matsuguma1,2, Motoko Kawashima2, & Kazuo Tsubota2
1 MILESTONE, Musashino City, Tokyo, Japan
2 Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan

Shinichiro Matsuguma is an outreach worker for hikikomori youth. He is a representative of MILESTONE, an organization which provides strengths-based coaching to the social withdrawal youth in Tokyo, Japan. His contact e-mail address: milestone0201@gmail.com

Introduction

            Hikikomori, social withdrawal, has gained public attention in Japan in recent decades (Li & Wong, 2015). It is defined as “the abnormal avoidance of social contact, typically by adolescent males” (Hikikomori, n.d.). The number of hikikomori aged between 15 and 39 years is estimated at approximately 541,000 in Japan (Nihon Naikakufu, 2016), and this phenomenon has gradually been reported internationally (Kato et al., 2012). The cause of hikikomori varies. Some clinicians and health professionals claim that some forms of hikikomori are caused by psychiatric disorders (Kondo et al., 2013; Hattori, 2006; Nagata et al., 2013; Wong, 2009). However, non-clinicians such as social workers and educators claim that hikikomori represents one aspect of the diversity present among youth (Wong, 2009) and resist regarding hikikomori as medically or psychologically abnormal (Borovoy, 2008; Can & Lo, 2014). Instead of pathologizing, they provide various training programs such as social skills training (Borovoy, 2008; Teo, 2010; Krieg & Dickie, 2013), emotional management (Hattori, 2006), and interpersonal skills (Wong, 2009) to overcome their difficulties with social interaction.

In this case study, the authors propose a new approach for hikikomori based on the strengths-based theory of positive psychology. Psychological strength is defined as “a pre-existing capacity for a particular way of behaving, thinking, or feeling that is authentic and energizing to the user, and enables optimal functioning, development, and performance” (Linley, 2008). It is a capacity that can be developed by optimizing the use of unique individual patterns of feeling, thinking, and behavior dependent on the context, while avoiding both overuse and underuse of strengths (Biswas-Diener, Kashdan, & Minhas, 2011). (e.g. overuse of kindness becomes emotional promiscuity; underuse of kindness becomes indifference (Freidlin, Littman-Ovadia, & Niemiec, 2017). Existing literature reports that people who utilize strengths feel happier, less depressed (Seligman, Steen, Park, & Peterson, 2005) and have high self-esteem (Proctor, Maltby, & Linley, 2011) in healthy samples, as well as less hopelessness in clinical settings among inpatients with suicidality (Huffman et al., 2014). Although several research studies on positive psychology and strengths intervention have been conducted across a wide range of populations over the last two decades (Ghielen, van Woerkom, & Meyers, 2017; Quinlan, Swain, & Vella-Brodrick, 2012), there are no studies of psychological strengths among hikikomori.

The following case is an example of the possibility of strengths intervention for hikikomori to breakthrough and take a step into the real world. The authors obtained informed written consent from the participant and his parent authorizing publication of clinical case. His anonymity has been preserved.

Case Study

The authors present the case of a 17-year-old male raised by a single mother since childhood. At age 9, he refused to go to school and became a hikikomori due to a perceived lack of purpose and meaning. He disliked what he perceived as a conformity-valued school culture and strict school rules often seen in the traditional Japanese educational system. He experienced feelings of constriction and agony from social pressures and constantly felt the need to fit in. Since then, he stayed in his room. He started to play online video games for at least seven hours a day and sleep during the day and be awake at night, only to leave his room to eat (see Table 1). At the age of 15, a friend he had made through online games asked him about his career course via online chat, which prompted him to think about it. He ended up concluding there was no reason to go to high school without anything he wanted to do in the real world. This resulted in feelings of hopelessness. He had a lot of agony as he searched for meaning in life in his room. At the age of 15, he was diagnosed with moderate depression, which was being treated with medication, and hospitalization was recommended. However, he refused hospitalization since he was opposed to restriction and did not see the point of treatment for his depression since he had no meaning in life. At that point, he “literally wished to become a non-player video game character and expunge his existence in the real world.” He suffered agony from self-hatred without knowing his reason for existence at the age of 17. He attempted suicide by hanging twice in his room. His mother brought him to some counseling institutions, but he subjectively perceived “they just listened to and empathized with” him, which he stated he did not need because he “had someone to talk via online video game.” Thus, he ceased to go to the counseling institution after the second visit.

Table 1
Typical Daily Life Before and After the Intervention and 3 Months Follow-up

His mother contacted the authors via our website, as she was interested in pursuing an alternative treatment for him. Following the client’s consent, the outreach took place once a week between July and September 2017. At the first meeting, his face was pale due to lack of exposure to sunlight. During the session, the positive psychology coach conducted strengths intervention by listening to his stories about his success, accomplishments, and flow experiences in the online video games. Based on the criteria for strengths-spotting (Kondo et al., 2013), the coach identified his strengths and helped him recognize his own strengths by facilitating him to think about the good aspects of each of them. For example, he played 50 vs. 50 match-type games via a network when he was 13. This game required team play, meaning that players need to cooperate with each other online; however, there are many who use violent language and have no manners, causing unnecessary arguments and conflict within the team during the battle. Some players even get upset and leave the team because of this violence. He saw this situation as “ridiculous and time-wasting,” failing to align with the purpose to play: to win and to have fun. Therefore, he started to create his own team without publicizing his actual name and age and recruited another 49 team members with the simple rule of no violent language or conflict, which allowed him to recruit well-mannered players and have no time-wasting during the battle for the sake of the meaning and purpose to play. Since he valued the meaning and purpose as a team leader, he tried to make his team bigger, creating a warm atmosphere to make every member feel welcomed, which led him to recruit another 49 team members successfully and always remain a higher rank.

While listening to his successful story and some other positive experiences, the same and consistent pattern emerged in his thinking, feeling, and behavior. He always desired to make his team bigger for practical and efficient reasons, tried to look for agreement for preventing unnecessary emotional conflicts within the team, and valued the purpose and meaning to play. The coach named these patterns as the strengths of “inclusion,” “harmony,” and “meaning,” respectively, and encouraged him to appreciate these strengths by eliciting positive aspects of each strength such as having tolerance for diversity for “inclusion,” making peace for “harmony,” or helping others to focus on the purpose for “meaning.” Then, the positive psychology coach made an attempt to raise the client’s self-confidence by mentioning that even though he was not attending school, in the online video game world, he had actually been developing his strengths. By hearing that, he came to realize that he had strengths for the first time in life because he had taken these natural patterns for granted, misunderstanding that everyone does not think and behave in the same way. The coach encouraged him to see school as a place to develop his strengths as a playground for baseball players or a skating rink for skaters. Since using strengths brings people energy and a sense of satisfaction, which he had already experienced through video games, he became motivated to use and develop his strengths in the real world, too. Also, because he always thought too much about the meaning and purpose of life, the coach pointed out that he was overusing his strengths of meaning and encouraged him to reduce the emphasis he was placing on this. Instead, the coach encouraged him to leverage his strengths of inclusion and harmony to promote success in the real world as he had done in online video games.

Two months later, he decided to go back to school with the motivation of improving his positive assets. When he spent time in school, he intentionally made an attempt to utilize his strength as he did in the video game. To make friends with his classmates, he utilized his strengths of inclusion and harmony by approaching a leader of the class and looked for common ground and similarities. He already knew from the video game experience that once he gained the attention of the leader, the followers followed, thus enabling him to make friends one after another and expand his friendship circle in the most efficient and successful way. This is a method that he applied to build connections in making his team bigger in the video game, utilizing the strengths of inclusion and harmony.

Our strengths-based outreach took place for three months, and his self-report self-esteem (Rosenberg Self-Esteem Scale) and subjective vitality (Subjective Vitality Scale) slightly increased at post-intervention time point, and dramatically increased at three months following the intervention. Moreover, his self-report depressive symptoms (Kessler Psychological Distress Scale) decreased over this period too (see Table 2). Furthermore, his lifestyle dramatically changed and the length of time spent on the internet significantly decreased too (see Table 1). He is currently in the last year of high school and preparing for university entrance examination. He is now willing to study psychology or philosophy at college to find meaning in life.

Table 2

Results of RSES, SVS, and K6 Scores

RSES: Rosenberg Self-Esteem Scale; SVS: Subjective Vitality Scale; K6: Kessler Psychological Distress Scale

Discussion

This case study illustrates a strength-based approach for hikikomori, applying their strengths in online video game to the real-world setting. By gaining the language of strengths for his recurring patterns of thinking, feeling, and behavior that lead to success in video games, the client described in this case study became aware of the fact that he had his own strengths, which led him to reconstruct his identity from a positive viewpoint and eventually increased his self-esteem and subjective vitality and decreased depressive symptoms. This phenomenon often occurs because people tend to be blind to their own strengths (Biswas-Diener et al., 2011) and use of strengths is positively associated with self-esteem (Proctor et al., 2011; Wood, Linley, Maltby, Kashdan, & Hurling, 2011) and vitality (Wood et al., 2011), and negatively associated with depressive symptoms (Seligman et al., 2005) in healthy samples. By utilizing his positive assets, he successfully took a first step in his environment.

Since there are various causes for hikikomori including psychiatric or developmental disorders, the authors cannot overgeneralize this result. Further studies are needed to evaluate the effectiveness of strengths intervention on hikikomori’s psychological conditions with a larger sample as well as the versatility of this approach to understand the mechanism of this process. However, this case study sheds light on a new aspect of helping hikikomori by emphasizing the importance of focusing on strengths.

References

Biswas-Diener, R., Kashdan, T. B., & Minhas, G. (2011). A dynamic approach to psychological strength development and intervention. The Journal of Positive Psychology, 6(2), 106-118.
Borovoy, A. (2008). Japan’s hidden youths: Mainstreaming the emotionally distressed in Japan. Culture, Medicine and Psychiatry, 32(4), 552-576.
Chan, H-y., & Lo, T-w. (2014). Quality of life of the hidden youth in Hong Kong. Applied Research in Quality of Life, 9(4), 951-969.
Freidlin, P., Littman-Ovadia, H., & Niemiec, R. M. (2017). Positive psychopathology: Social anxiety via character strengths underuse and overuse. Personality and Individual Differences, 108(Supplement C), 50-54.
Ghielen, S. T. S., van Woerkom, M., & Meyers, C. M. (2017). Promoting positive outcomes through strengths interventions: A literature review. The Journal of Positive Psychology. doi: 10.1080/17439760.2017.1365164.
Hattori, Y. (2006). Social withdrawal in Japanese youth. Journal of Trauma Practice, 4(3-4), 181-201.
Hikikomori. (n.d.) In English Oxford Living Dictionary. Retrieved from  https://en.oxforddictionaries.com/definition/hikikomori.
Huffman, J. C., DuBois, C. M., Healy, B. C., Boehm, J. K., Kashdan, T. B., Celano, C. M. …Lyubomirsky, S. (2014). Feasibility and utility of positive psychology exercises for suicidal inpatients. General Hospital Psychiatry, 36(1), 88-94.
Kato, T. A., Tateno, M., Shinfuku, N., Fujisawa, D., Teo, A. R., Sartorius, N. … Kanba, S. (2012). Does the ‘hikikomori’ syndrome of social withdrawal exist outside Japan? A preliminary international investigation. Social Psychiatry and Psychiatric Epidemiology, 47(7), 1061-1075.
Kondo, N., Sakai, M., Kuroda, Y., Kiyota, Y., Kitabata, Y., & Kurosawa, M. (2013). General condition of hikikomori (prolonged social withdrawal) in Japan: Psychiatric diagnosis and outcome in mental health welfare centres. The International Journal of Social Psychiatry, 59(1), 79-86.
Krieg, A., & Dickie, J. R. (2013). Attachment and hikikomori: A psychosocial developmental model. The International Journal of Social Psychiatry, 59(1), 61-72.
Li, T. M., & Wong, P. W. (2015). Youth social withdrawal behavior (hikikomori): A systematic review of qualitative and quantitative studies. The Australian and New Zealand Journal of Psychiatry, 49(7), 595-609.
Linley, P. A. (2008). Average to A+: Realising strengths in yourself and others. Coventry: CAPP Press.
Nagata, T., Yamada, H., Teo, A. R., Yoshimura, C., Nakajima, T., & van Vliet, I. (2013). Comorbid social withdrawal (hikikomori) in outpatients with social anxiety disorder: Clinical characteristics and treatment response in a case series. The International Journal of Social Psychiatry, 59(1), 73-78.
Nihon Naikakufu. (2016). Wakamono no seikatsu ni kansuru chōsa hōkokusho (Research report on youth life). Tokyo. Nihon Naikakufu (Cabinet office of Japan).
Proctor, C., Maltby, J., & Linley, P. A. (2011). Strengths use as a predictor of well-being and health-related quality of life. Journal of Happiness Studies, 12(1), 153-169.
Quinlan, D., Swain, N., & Vella-Brodrick, D. (2012). Character strengths interventions:   Building on what we know for improved outcomes. Journal of Happiness Studies, 13(6), 1145-1163.
Seligman, M. E., Steen, T. A., Park, N., & Peterson, C. (2005). Positive psychology progress: Empirical validation of interventions. American Psychologist, 60(5), 410-421.
Teo, A. R. (2010). A new form of social withdrawal in Japan: A review of hikikomori. The International Journal of Social Psychiatry, 56(2), 178-185.
Wong, V. (2009). Youth locked in time and space? Defining features of social withdrawal and practice implications. Journal of Social Work Practice, 23(3), 337-352.
Wood, A. M, Linley, P. A., Maltby, J., Kashdan, T. B., & Hurling, R. (2011). Using personal and psychological strengths leads to increases in well-being over time: A longitudinal study and the development of the strengths use questionnaire. Personality and Individual Differences, 50(1), 15-19.