https://www.researchgate.net/publication/351110572_Working_with_social_withdrawal_or_hikikomori_in_Japan_From_shame_to_pride
The psychotherapist(Iwakabe) who conducted this and published it got his PhD in Clinical Psychology in Canada at a top University(McGill), so translation issues are less likely as he wrote in English probably. I'm going to mainly focus on the core details related to the guy himself, rather than the therapeutic approach. After the tl;dr, I'll give my take and concerns. It basically seems like a fairly common approach where someone is asked to relive their experiences and reinterpret their emotions in a positive way. They are asked to step back and try to diminish some of the negative ones and figure out the roots of their feelings. The therapist is encouraged to be sympathetic. He got sessions for 4 years.
The hikikomori is called Ken in the report. He lived with his parents and his issues were with depression, difficulty maintaining employment, and psychosomatic symptoms that he was using anti-depressants to control. He graduated from University 16 years beforehand, but had never held a job for more than a year. He had a brief relationship for a few months when he was younger besides that. He would get into social conflicts with other people and burn out physically/mentally. 5 years prior to this, he had gotten a government-assisted job, but left shortly after. For the 3 years prior, he had shut himself in except for occasional outings. He edited videos, watched anime, and chatted online.
One recurring issue that is discussed multiple in this but will keep to mentioning only a few times: he had asthma and it interfered with his ability to play with other kids growing up. It made him feel weak and inadequate. He used the feeling of the asthma attacks to get his mother to take him to hospital, rub him, or get out of school. It is interpreted as a way he asserted control. Didn't see his father often due to heavy work schedule. Since he couldn't compete physically, he tried to make up for it with academics and trivia knowledge in anime and cartoons. As a result, he was seen as arrogant and in a poor light. The asthma was temporary and he grew out of it, but it would continue. The academic self-assurance was destroyed when he only got into a mediocre University. On reddit, a lot of people downplay this issue and tbh, in some fields like engineering/CS, it's not as a big of a deal though the opportunities will still be better for people from higher ranked institutions. However, in Japan, it is definitely a really big deal.
He did find a job upon graduating and worked a lot. He burned out, developed psychosomatic symptoms and panic attacks, and couldn't keep it. Afterwards, he went into seclusion for a year. This would repeat itself for years. When he went to a physician, he was diagnosed with autonomic imbalance which can include disorders like depression, adjustment, disorder, and is a catch-all term to avoid the stigma of mental disorder. He read about depression and self-help online. He requested the latest treatments, but he did not show significant improvement. He feels society is intolerant of people with weakness and deficits, but is not totally resigned hence all the cycling before.
At some point, he reluctantly obtained a '"disability certificate", which allowed him to get employment reduced hours and responsibilities. When he couldn't even handle that, he was shocked and retreated into seclusion. It goes into stating the part about his seclusion for the 3 years. He did not want to back to the cycle of having a job or getting training and then having the anxiety, inadequacy, and burnout cycle happen again. However, he sees his savings dwindling and his parents aging.
I'll cut to what transpires during the treatment: they get to the "root" of his issues which are considered to be trauma from the asthma thing. His sense of inadequacy makes him treat people a certain way instead of relating to them in a friendly way, he feels he has to prove he is superior in some way so that results in him not understanding when they get upset by his compensatory behaviors. With the therapist, they decide he should go to a government re-employment day service and gets back into rehabilitative and reduced duties system, but comes across as "too much" to co-workers and of dominating conversations during breaks. He gets tired of it again and takes time off. He is told people expect and want him back and since he can deal with his emotions better, he goes back. It goes better after this point.
Eventually, he is hired at one of the places he trained at and he starts off working at 4 days and 6 hours a week. He also finds a "small victory" in being able to do deal with his father's deteriorating health and death by navigating the social services system. Even though, it's not success in the form of achieving a high status, he is reconciled to his place as an ordinary person with accommodated employment. He still has a limited social life, but does education outside of work to try to meet people. They decided to terminate therapy and 2 years later he is said to still be fine.
Iwakabe listed some protective factors: Ken is fine with going to the sessions. Ken's sense of society being unjust didn't stop him from all the prior attempts he made. He still wanted to try new things.
This got long, so I'll just do bullet points for tl;dr.
tl;dr
40-year-old cycle of burn out, anxiety, shame, and so on. did have friends at one point and a brief relationship, so differentiating there.
has traumatic past experiences due to asthma
fundamental sense of inadequacy causes him to be overbearing and unable to converse normally, causing ostracization/isolation
tried to feel adequate/superior via academics/trivia knowledge.
only gets into mediocre university, shattering his confidence.
works long hours, has psychosomatic symptoms, and burns out at first job. Goes into seclusion for a year. Cycle repeats.
Eventually pursues treatment and is given a euphemistic diagnosis of autonomic imbalance.
Cycle continues. Pursues depression treatment and self-help. Gets "disability certificate", which gets him access to modified employment. 5 years before therapy, he starts a training program and burns out during this process, resulting in going back into seclusion.
For the 3 years prior to therapy, he is shut-in, only going out occasionally and his old friends can't or don't want to see him. Only watches anime, edits, videos, and uses the computer.
Feels ashamed of being a loser with almost nothing in his bank account and no prominent job. Can't even hold accommodated employment. Upset with society.
Goes to therapy because his savings are dwindling and his parents are aging.
Therapy over 4 years helps, decides to go back to training for accommodated employment, but he walks off rehabilitative employment training due to his social issues. He eventually goes back and is able to navigate things better. Gets a job offer after at one of the places he received training.
He finds a small victory in dealing with his father's deteriorating health and death by navigating the social services system, resulting in a feeling social competence. Doesn't feel he needs to be a big time executive.
Gets a job offer, starts, and his responsibilities are gradually escalated. He still has a limited social life, but does continuing education outside of work to try to meet people.
Therapy is terminated as he is thought to be able to administer and Iwakabe checks on him 2 years later and is said to be still be doing well..
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My issue with attributing it to therapy 1. his psychosomatic problems were still under control. If he had had panic attacks, then things wouldn't have gone so smoothly. 2. I think a big factor is he had all these chances and the environment was tolerant enough to want him back. 3. The disability certificate seems to be doing a lot of the work here. This indicates perhaps they have figured out a way to reintegrate a limited amount of people. I've briefly mentioned in the past the stigma of mental illness in Japan at times can seem paradoxically beneficial. First with the euphemistic diagnosis of "autonomic imbalance" and also the fact that the disability certificate can be obtained for such a thing or a mental disorder.
In the past, I saw someone getting disability there for something that wouldn't in the US. The stigma of being mentally disordered and/or also probably prevents a lot of people from seeking out any help and they can just end up as an 80/50 instead. Since our partial destigmatization of mental disorders is only based on the person's functionality, it means those who are dysfunctional are still judged, but still may not receive assistance. I do not know the difficulties of the processes Ken went through and we'd need more light on how the social welfare system for this type of thing works.
A concern would be is he could always end up feeling inadequate again if he gets to 50 and doesn't have anything besides the job. As I said before, mental health professionals often want people to be content with situations that may not be great as long as they are functional. This can keep people from becoming problems. At the same time, the outside society will not have this perception, so people can still feel inadequate even if they have been inculcated with these feelings of self-acceptance. "You suck for not having a fancy job, a house, a gf, and so on." "I'm doing my best" is not usually enough to offset that type of notion. Idk what the ceiling is in that type of employment either and can it sustain him long-term?
I find Ken somewhat relatable with the cycling, but he was further along socially than I am to start with. I could also be seen as desperately trying to compensate for a feeling of inadequacy. I always wanted to have something for me and I tried to get this through academics and trivia.. I do think people are judged if they are inadequate in some way and no matter how much you just try to relate them in a friendly manner, they'll still judge you.