FY 2018 Bulletin, Issue 7

What we have learned from our support of a hikikomori: anexample of continued support prompted by health surveys
Stem Center, Community Support Division
Public Health Nurse – Kazuko Saito
Psychiatric Social Worker – Reira Onuma
Yamamoto Health and Welfare Division, Public Health Nurse – Shizue Yokoyama
Public Health Nurse – Kana Ito

Introduction
Since FY 2012, we have conducted a health survey for individuals affected by the Great East Japan Earthquake(survey organizers: Miyagi Prefecture & the town of Yamamoto). One individual who was flagged for a follow-up
visit by this survey was a hikikomori (a shut-in, or social recluse). Since regular home visits to this individual
affected positive change in their life and the lives of their family members, we report the details of this case here,
focusing primarily on our relationship with the individual.
1. Overview of the town of Yamamoto and the extent of the disaster damage it sustained
Yamamoto is located on the border between Miyagi and Fukushima Prefectures. It is often called the Shonan(a famous, temperate beach city near Tokyo) of Miyagi, and is a warm and sunny place. It has a population ofapproximately 12,000, with an approximately 38.6% rate of aging. It has two Type B Continuous Employment
Support Offices. In the Great East Japan Earthquake and Tsunami, approximately 40% of the town was flooded,
637 people died, and approximately 6,000 individuals were evacuated.
2. Case introduction
Name: Ms. AAge: Late 20s
Sex: Female
Family structure: Five-person family; has a father, mother, elder brother,and a younger sister. Her brother and sister live independently. Her father often only returns on his days off,and during the week, it is usually just Ms. A and hermother at home.
History:
Was born in the area, and as a child, attended elementary
school without incident. She advanced to middle school,
but because she was a quiet child, she was ignored
throughout the first semester of her first year. After summer vacation, she turned truant. She would sometimes visit
the nurse’s office, and she managed to go on her ninthgrade school trip. She did not advance to high school andbegan to stay at home. At the age of 19, on her father’s
recommendation, she obtained her driver’s license. At present, she helps with chores around the house, takes hermother to and from the hospital, and goes grocery shopping; she is always with her mother. Her circadian rhythms
are normal, but she spends most of her time in her room.
She is currently undergoing treatment for fatty liver by alocal doctor but has no history of seeing a psychiatrist.

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Early 60s

Late 50s

Early 30s,lives in S.
City

Early 20s,lives in S.
CityFigure 1. Family StructureWhat we have learned from the Tagajo Disaster Survivors Health Support Project3.

Progress
Ms. A was flagged as needing follow-up in the FY 2015 disaster-survivor health survey (K6 score: 16), and wegave her a visit. During our first visit, we noted the following: she was in a hikikomori state, she had a high K6
score, and she had a BMI > 30. These points made her eligible for continued support. We, therefore, began to conduct
regular home visits.
Visits were carried out by a Yamamoto public health nurse and a Miyagi Disaster Mental Health Care Center
public health nurse. On our first visit in July 2016, Ms. A had unkempt hair, wore pants and a T-shirt, had nearly no
facial expressions, and did not say a word. When asked a question, she would merely tilt her head in assent or
disagreement, and her mother answered on her behalf.
Given that state, we were worried that she might have a mental disability and were unsure of how to interact withher. To confirm her family’s feelings, we met with her father as well. He said, “I think that normal employment
might be difficult for her. But this can’t go on. We’ve got to do something,” and “I want her to at least interact withsomeone outside of the family. I want her to work for at least half the day.” We were surprised that Ms. A’s father
knew her that well, and we decided to set a treatment goal of “regular visits to an assisted employment center.”

We developed the following 3-part support guideline: ① We would visit Ms. A regularly (once monthly) todetermine her needs and build a relationship of trust. We would use different media to build this relationship(cards, origami). ② We recommended that she make use of an assisted employment center (by referring her toa hikikomori support facility, etc.). ③ We would meet with her father to discuss how she was doing and hisexpectations. After formulating these guidelines, we began to provide support.

Fathero Normalemployment
will be difficult. But
the status quo cannot
go on.

o I’d like her to work

for at least half theday.

o I’d like her to interactMother※The father confirmed themother’s opinions.
o You don’t need to pro-vide her with hikikomori counseling.

PHNo Wow, the father

knows his daughter
well.

o Let’s support her sothat she can start going to an assisted
employment center.

with people outside
the family.

Figure 2: Consultation With the Father (To Gauge His Thoughts and Feelings and His Wife’s as Well)

During our visits, we would bring cards with us and play cards with Ms. A and her mother. At first, we had toencourage her at every turn, but after three months of visits, she slowly began to deal the cards herself, suggest
games like Sevens, and even talk and smile. We even saw her begin to think of strategies to win our games. On ournext visit, her mother brought out a pack of cards that she had bought.
Next, we brought origami paper with us and folded cranes with Ms. A and her mother. By the following visit, hermother had also bought origami paper and an origami book. Ms. A enthusiastically showed us what she’d foldedfrom the book, and she patiently taught us how to fold some of them.
We had told her father during our first meeting with him that hikikomori support centers exist. At one point, after
her father had retired, he took her to see it. However, she was quite unwilling to visit the center, so her father would
take her and bring her back once a week. On the day of our visit, we made sure to tell her that “if you don’t likegoing, it’s okay if you’re honest about it.” However, she slowly began to visit the center herself, and a year later,even after her father had returned to work, she began to visit the center herself by train. Now, whenever Ms. A wasout of the house, her mother would happily tell us, “She’s started to talk about what she did at the center during theday!” “The day before she goes, she’ll take a bath and wash her hair;” and “She’s started buying clothes for herself.”－ 106－

FY 2018 Bulletin, Issue 7

At present, Ms. A has been visiting the employment center for one-and-a-half years. Her lifestyle has broadened
considerably, she smiles and speaks often, and she is happy to visit the center (2-3 times a week). She has begun totake on responsibilities there, such as teaching origami to other center-goers. When we asked her about what it was
like going to the center, she said, “I’m happy that I get to experience different things there;” “Before I wanted to talk,I just couldn’t;” and “I’m glad that I can be of use there.”

4. Discussion
Approximately two years have passed since we began visiting Ms. A. Her lifestyle has broadened considerably,
she smiles and speaks often, and she happily goes to the center. Her parents have changed alongside her, and this has
encouraged her to change even more. The reasons for these changes include the following: we continued regular visits
to build a relationship of trust with Ms. A and her family; we provided support tailored to her situation; we used cards
and origami to assess her skills; we visited as a team, so one person was able to work with Ms. A and another withher mother, and we continued to reassess our support even when we received a good response.
Conclusion
The changes Ms. A underwent precipitated changes in her family, and we believe that this synergistic effect is whatbrought about the excellent results seen in this case. In the future, we plan to continue to provide close support toboth Ms. A and her family, even as we check in with them about their thoughts and feelings along the way.

Picture 1. Some of Ms. A’s Creations (Roses)

Picture 2: Another of Ms. A’s Creations (A Bouquet)

Finally, we will share some of Ms. Yamamoto’s comments (she is a public health nurse at the Yamamoto Healthand Welfare Division), titled “How I Feel After 2 Years of Providing Hikikomori Support.”
This was the first time I had been involved in hikikomori support work since becoming a public health nurse.
Although I had started making my home visits, I didn’t know what to do; I didn’t know how to pick a goal, and I
was worried that she wouldn’t change even with my support. I was a mess. However, because I was part of a
support team, I managed to convince myself that it would be fine, and I jumped in.
I got to learn a lot about hikikomori support, and I started attending training workshops. At one of them, someone who was once a hikikomori spoke to us, and he told us that he eventually managed to find full-time employment. Upon hearing that, I realized that people like him did exist. I began to believe that my support client wouldchange too, and I decided to continue with the work.
First, I decided to build a relationship of trust. I tried to pick something that wouldn’t be burdensome and thatMs. A herself would find fun; I went with origami. She eventually started doing it on her own, and I realized thatall she needed was a small push to help her find something she was good at. I was also, at first, unsure if it wasalright to play cards with her during a home visit; when we started playing, however, I noticed that she began tosmile. Playing cards was also a great way to evaluate her mental capabilities. I think it was a great tool.
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What we have learned from the Tagajo Disaster Survivors Health Support Project

I’m also grateful to her father for being so decisive. After introducing her to the hikikomori support center, webegan to see one change after another, and I began to feel confident about, and happy with, our work. We sawchanges not only in Ms. A but in her family as well (especially her mother). These led to further changes in Ms.
A, which then boosted my confidence.
Ultimately, I presented this case at an academic conference, and upon being asked a plethora of questions byother specialists, I realized just how interested they were in it. I know that this experience would be of immense
value to me in my future career as a public health nurse.
This manuscript was partly reproduced for a joint presentation made by the town of Yamamoto and the Miyagi
Disaster Mental Health Care Center at the 9th Annual Meeting of the Tohoku Mental Health and Welfare Association, in Yamagata, on September 30, 2018.
Ethical Considerations
We explained our work verbally to the support target and got her consent. This support was also provided withthe approval of the Miyagi Disaster Mental Health Care Center Ethics Committee.

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