The scope and nature of prolonged social withdrawal in Israel: An initial quantitative and qualitative investigation.

OBJECTIVE: Over the past few decades, prolonged social withdrawal (PSW) among young people has been recognized in several countries. Most research has been quantitative and focused on the characteristics of PSW individuals and their families. Little attention has been given to the valuable perspective of professionals providing service to this population. The purpose of the present study is to identify the characteristics of PSW in Israel, where this phenomenon has not been researched yet. For this initial investigation, the study will utilize a combination of quantitative self-report data from parents of PSW individuals, as well as qualitative data gathered from interviews with mental health professionals who work with this population.
METHODS: Quantitative data were derived from records of referrals by parents of 121 PSW individuals, and later categorized into apparent characteristics of PSW. Qualitative data was collected through semi-structured interviews conducted with 19 professionals experienced in treating PSW, and later analyzed in a thematic analysis process.
RESULTS: Findings from the quantitative data revealed a majority of males (70%) with an average age of 24.2, with previously diagnosed psychiatric conditions (64%). Findings from the qualitative data exposed frequently reported characteristics of PSW individuals and their families, out of which five themes emerged: Family Dynamics, Psychological Characteristics, Typical Behaviors, Past Difficulties, and Present Challenges.
CONCLUSION: This study is the first to identify and report characteristics of PSW in Israel, which are consistent with previous research reported in other countries. The study is highlighting familial characteristics as well as individual ones, while also considering the broader socio-cultural context. These findings draw attention to the importance of notifying the general public, clinicians, researchers, and policymakers in Israel and beyond to the concerning problem of PSW, while contributing to the efforts to develop a map of this barely explored territory.

Introduction

A particular type of severe and prolonged social withdrawal among young people was first noticed in Japan during the 1970s and was referred to as Hikikomori (Saito & Angles, 2013; Teo & Gaw, 2010). Since then, the phenomenon has been reported in various countries including Hong-Kong (Wong et al., 2015), Korea (Lee et al., 2013), Taiwan (Wu et al., 2020), India, USA (Teo et al., 2015), Spain (Malagón-Amor et al., 2018) France (Chauliac et al., 2017) among other places, and thus it is increasingly considered as a severe worldwide condition (Bommersbach & Millard, 2019; Kato et al., 2019). In Israel, PSW has not yet been recognized and thus not reported in mental health surveys (Farbstein et al., 2010) or addressed as a problem of public concern.

In the current study we present the findings of the first effort to identify the characteristics of PSW in Israel and professionals experiences in treating them.

Although a consensus definition has not yet been established, Kato et al. (2020) have recently proposed the criteria should include: (a) social isolation in one’s home; (b) for at least 6 months; (c) with significant functional impairment or distress associated with the isolation. Research has reported that onset typically occurs during adolescence or early adulthood (Koyama et al., 2010), prevalence is approximately 1% to 2% (Koyama et al., 2010; Wong et al., 2015), and it is more common among men (Tajan et al., 2017; Li & Wong, 2015) and people with various psychiatric disorders such as: schizophrenia, mood disorders, anxiety disorders, personality disorders, developmental disorders, substance abuse and internet addiction (Kondo et al., 2013; Li & Wong, 2015; Stip et al., 2016; Tateno et al., 2012; Teo et al., 2015). However, there is still uncertainty on whether PSW is caused by, correlated with, or causes psychiatric disorders (Wong et al., 2019).

Documented efforts to categorize PSW individuals by characteristics appear in the literature. Of note is the division between ‘primary’ versus ‘secondary’ Hikikomori, depending on the presence or absence of underlying mental or personality disorders (Kato et al., 2012); ‘hard-core’ versus ‘soft’ subtype depending on the severity of isolation (Heinze & Thomas, 2014) and ‘overdependent’, ‘maladaptive interdependent’ or ‘counter-dependent’, depending on family structure and system dynamic factors (Li & Wong, 2015). No studies to date, however, have examined these distinctions (Wong et al., 2019).

As global reports exhibit the expanding magnitude of the phenomenon over time (Chan, 2016), it is important to raise more awareness on the subject on a national level. On a global scale, identification of the phenomenon in more countries contribute to the efforts to map it and study the similarities and differences in characteristics among diverse countries. In addition, most research on PSW has been quantitative and there is a lack of qualitative reports on the phenomenon (Tajan, 2015). In the most rigorous systematic review including 42 articles on the topic (Li & Wong, 2015), only 12 were qualitative and only 2 included the perspective of clinicians (Wong, 2009, 2012). The importance of the qualitative perspective stems from its potential to give a glimpse into the subjective experiences of both those who cope with PSW and the professionals who work with them. While Wong (2009, 2012) investigated the perspective of clinicians largely by using focus groups of 10 social workers, the current study will employ in-depth interviews with a larger and more diverse group of mental health professionals.

Aims of the study

The primary aim of the first study is to present the appearance and characteristics of PSW in Israel. The second study focuses on the experience gained by professionals who work with this population.

Study 1

Method

Research background and setting

This study was based on a retrospective analysis of information provided largely by parents regarding their son/daughter, who referred to ‘Outreach’ – a private mental healthcare service in Israel. This service, established by the first author (OH), offers therapeutic and rehabilitative services, delivered in clients’ homes, for populations who are home-bound for physical and/or mental reasons, including PSW.

The sequence of the intervention consists of three main stages:

Assessment: Including intake sessions to reach a comprehensive formulation, risk assessment, and initial treatment plan.

Engagement: Typically, a therapist will be assigned for home visits in order to engage the PSW individual, and a second therapist will work with the parents routinely at the clinic.

Treatment: A range of individual and family interventions provided by the team or brokered, including psychotherapy, pharmacotherapy, practical support (promoting recovery), and family interventions.

Participants

Inclusion criteria were based on the current body of knowledge on PSW: age under 40 (Tajan et al., 2017), socially isolated in one’s home for a minimum of three months (Lee et al., 2013) and presenting significant functional impairment (Kato et al., 2020). All service referrals to ‘Outreach’ between August 2016 and February 2020 were reviewed (2,111 cases). Out of the total of 229 referrals who met the above criteria, 108 were excluded due to missing data, and the remaining 121 constitute the current study sample.

Data collection and analysis

Data were extracted from the records of the ‘Outreach’ service. Since none of the information collected could reveal the identity of participants, consent was unnecessary. The study was approved by the ethics committee of the University of Haifa, Israel.

Results

Characteristics of PSW individuals

Table 1 displays the demographic and clinical information from the 121 individuals who were included in the study. The majority were men with PSW, over 18 who have a variety of past or current psychiatric diagnoses.

Table 1.

Demographic and Clinical Characteristics from 121 PSW Individuals.

Variable	Referral frequency (%)
Gender
Male	85 (70)
Female	36 (30)
Age (mean age: 24.2)
Under 18	25 (20)
18–25	47 (39)
26–40	49 (41)
Length of social withdrawal
Up to 1 year	46 (38)
1–5 years	57 (47)
Above 5 years	18 (15)
Presence of a past or current present psychiatric diagnosis
Yes	78 (64)
No/unknown	43 (36)

The data on the diagnoses were provided by the applicants themselves, exclusively limited to formal diagnoses (appearing in the DSM or ICD) assigned to them by professionals. The diagnoses distribution was: Schizophrenia/Non-affective Psychosis (n = 23), OCD (n = 18), Mood Disorders (n = 16), Anxiety Disorders (n = 17), ADHD (n = 8), Personality Disorders (n = 7), Others (n = 9). Note that some individuals had more than one diagnosis.

Discussion of study 1

Results suggest that PSW is apparent in Israel with some characteristics similar to those reported in other countries such as being more prevalent among young men who remain socially withdrawn for considerable lengths of time (mostly 1–5 years: 47%) and who have been given a psychiatric diagnosis (64%).

These findings should be carefully considered within the unique local context. Israel has a competitive job market and military conscription for all citizens over the age of 18. In particular, men may be obligatorily recruited to fight in combat units (for 3 years) and culturally socialized toward it. This is a significant functional requirement which includes, among other things, extreme social exposure (acquaintance with new people, shared living, etc.). These requirements may lead young people with earlier functional difficulties and avoidance issues toward further withdrawal – before, during, or after their military service. It was already suggested that social demands might put pressure on adolescents and young adults, while failure to meet such demands could result in PSW (Furlong, 2008). The increase of these demands in Israel at the age of 18, later years of military service, may be one of the possible explanations for the high rate (nearly 80%) of PSW individuals past this age. Of note, the age of this sample was determined by the time of referral and not PSW onset.

The psychiatric diagnoses observed in the current sample resonate with those of other published reports (Chauliac et al., 2017; Malagón-Amor et al., 2018; Tateno et al., 2012), with the most common diagnosis being schizophrenia or other psychotic disorders (30%), followed by OCD (23%), anxiety disorders (22%), and mood disorders (20%). The relatively high percentage in the current sample of those with a psychiatric diagnosis (64% diagnosed and the rest either no diagnosis or unknown) may be biased by the help-seeking sample applied herein. However, it is possible that in Israel, similar to what was found in other countries like Spain (Malagón-Amor et al., 2015), primary Hikikomori – meaning no psychiatric diagnose is suitable – is less common.

Study 2

Participants were licensed mental health professionals from the fields of psychiatry, psychology and social work, who have had experience treating at least one PSW individual (as defined in section 2.1.2 above) or his/her family members. Participants were invited through snowball sampling method, using professional connections and advertising through social media and mailing lists.

A total of 48 professionals contacted us and 19 were found to meet the criteria and signed the informed consent, approved by the ethics committee of University of Haifa’s Psychology Department, after receiving a detailed explanation about the study. The sample included 13 (68%) men and 6 women, out of which 8 (42%) were psychologists, 7 (36%) social workers, and 1 (5%) psychiatrist, with an average experience of 14 years. Supplemental Appendix 1 summarizes the participants’ profiles and experience with PSW.

Since the professionals’ relevant experience varied considerably in terms of the number of PSW individuals or families they had worked with, we divided them into two groups: Group A – therapists with experience of 5 or more cases (11 participants), and Group B – therapists with less than 5 cases (8 participants).

Mental health professionals recruited for the study were asked to participate in a 1-hour interview, at a place of their preference. Participation in the interviews was completely voluntary and the participants could withdraw at any time. Following an explanation about the study, participants completed a short questionnaire with the following personal and professional data: Name, Age, Profession, Years of experience, Place of work (when treating PSW), Number of PSW treated and Length of the longest treatment. The semi-structured interviews were conducted, including 7 guiding questions that were determined by the research team (see Supplemental Appendix 2). All interviews were conducted by OH between January and August of 2018, digitally recorded, professionally transcribed, and proof-read.

Thematic analysis (Braun & Clarke, 2006) was adopted to investigate how participants characterized PSW. Authors OH and TK conducted the analysis, and DK and DR examined the findings while providing feedback. Initially, we read the full interviews and generated general motifs from each interview. Then we thoroughly scanned the transcripts for any comments which described characteristics of PSW individuals and their families, or any comments about the characterization of the phenomenon itself and highlighted those parts as relevant for further analysis. Next, we coded the relevant parts and generated a list of codes. This process was initially performed by OH, then repeated by OH and TK resulting in a list of 50 agreed-upon codes. Subsequently, we re-examined the codes and proceeded with focused coding, which resulted in a 19-category division. Finally, we formulated the categories based on discovered mutual links and crystalized five themes, which seemed to capture the essence of the professionals’ perceived characteristics of PSW: Familial Patterns, Personality Traits, Typical Behaviors, Past Difficulties and Present Challenges. As theoretical issues emerged, we reviewed the codes again and redefined them, with the active participation of the whole research team.

Frequent characteristics of PSW perceived by mental health professionals

In the process of coding the comments of the interviewees regarding characteristics of PSW, we counted the frequency of appearance of specific characteristics. This process was done with consideration of the number of cases that each professional was treating, as presented in Supplemental Appendix 3`. The most common characteristics that were mentioned by the more experienced professionals included: low parental presence, avoidant and enabling position of parents, parental fear and anxiety around child’s reactions, breach of trust of PSW individuals with their environment and limited ego strength of PSW individuals.

Among these, ‘low parental presence’ stands out with high frequency (36% of participants), referring to either physical or emotional presence, as one of the professionals explained:

(3) A greater issue is consuming the parents’ attention, great responsibility at work – be it doctors, military careerists, a business owner or midwife assisting home-birthing, so. . . Yes, parents are less present at home.

Similarly, the aspect of a parenting style which avoids confrontation with a PSW individual had the same appearance rate (36%). This position was described as sometimes maintaining the status quo. For instance:

(4) Due to various reasons, the parents’ ability to confront their child, for example – knock on the door, open the door etc. -is very low. . .some parents have a lot of anxiety. This parental position affects the course of withdrawal. Those who recover better are the cases when the parents are not avoidant.

Notably, 3 out of the 5 most frequently mentioned characteristics focus on the parental and family dynamics, rather than the PSW individuals. Although mentioned by the professionals, characteristics regarding individual psychopathology were excluded from the frequency count, due to lack of information on diagnosing procedures.

Themes of PSW characteristics as perceived by the therapists

Further data analysis revealed five themes, reflecting the therapists’ perception of the characteristics of PSW:

Family Dynamics

Psychological Characteristics

Typical Behaviors

Past Difficulties

Present Challenges

Family dynamics

A total of 14 (73%) of the professionals mentioned certain family dynamics and parental patterns as fundamental characteristics of PSW, sometimes even more central than the individual qualities. As one of the therapists stated:

(8) I feel that the notable characteristics are not those of the population itself but rather of their families. It usually occurs in places where there is ample anxiety on the parents’ side.

Other than anxiety of the parents that was already mentioned above, other subjective experiences of parents of PSW individuals were described:

(5) The notable issue is parental helplessness – it possibly originates in a great fear of intervening, confusion, embarrassment, deep-seeded differences between the parents, and even parental pathology. . . they are helpless in the sense of facing a situation that they feel like they have zero power of influence on, and so they finally accept it, as if having no other choice.

The parental helplessness demonstrated above contributes to what has been described by some respondents as enabling position, which unwillingly maintains the PSW situation, rather than changing it.

Based on the therapists’ reports, the perceptions held by PSW individuals toward their parents and their wider environment appears to be rather ambivalent. On the one hand, 3 (16%) of the clinicians reported resistance, clashing, and blaming by the young PSW toward the parents, and 5 (26%) reported breach of trust with the parents and the wider social circle. On the other hand, 6 (32%) proffesionals reported issues of dependency on the parents and a sense of neediness toward them:

(9) . . .we see a pattern of relationship between a person with a dysfunctional dependency and caregivers that accommodate to his needs.

Psychological characteristics

Another domain of characteristics mentioned by professionals refers to the psychological aspects of PSW individuals themselves, including personality traits, experiences and emotions. For example:

(14) I believe that there is a deep sense of despair and hopelessness that are reinforced over time. Since they don’t take action, they don’t experience, they don’t dare. . .and in turn they lose their faith in themselves.

Some professionals highlighted the weakness of ego forces, which lead to over dependency and a continuing need for support from parents and others.

Typical behaviors

A series of behavioral characteristics were mentioned by professionals as typical expressions of PSW, including enhanced use of technology, drug use, sleep disturbances, physical and environmental negligence, etc.

The excessive use of technology – sometimes referred to as addiction to screens – was mentioned by 5 (26%) proffesionals as an important characteristic of the population. Three of them (16%) further elaborated on the use of technology, commenting that it sometimes serves to create relationships in a virtual reality that replace engagement in actual reality. As one professional stated:

(5) One characteristic that stands out is that almost always there is a creation of a virtual reality and a sinking into such a virtual reality that replaces real life.

A most concerning characteristic that was mentioned by 15% of participants is suicidal behaviors and expressions, as manifested in the following:

(9) In many cases, there is a suicidal threat made by the youngster; actually, in every case we encounter (‘hundreds’), there is a so called ‘suicidal demon’ or suicidal shadow. . . With prior attempt or without, with intention or not. . .the suicidal theme is always there.

The suicidal threat sometimes creates what was referred to by one participant as a ‘balance of terror’ between the PSW individual and their immediate environment, allowing them to maintain the status quo as the parents or significant others are too afraid to take action.

Past difficulties

Various difficulties from the individuals’ history were mentioned as essential characteristics of PSW. Through this theme’s lens, PSW is perceived as reactionary to an event or series of events, often traumatic ones, including: childhood trauma of a social nature (rejection, violence, bullying) and/or of other backgrounds (accidents, crises), physical and emotional abuse in the family, academic challenges, struggle with structures, complicated relationships with the family, various types of psychopathology, etc. As one professional put it:

(10) I believe that every case began with a predisposition of anxiety that met difficulties in real life events in the past.

Present challenges

Nevertheless, the challenges of PSW individuals were not referred to as part of the past. In some cases, the difficulties continued into the present and were accompanied by newly formed ones. Some challenges relate to the state of withdrawal itself, as described by one of the professionals:

(16) I believe that many of these individuals experience themselves in the present as refugees. A refugee finds himself a small space to live, as he’s unable to feel belonging in any place he turns to, a sort of detachment. . . It’s a true sense of not having a place in the world, which at times may lead to suicide, and other times to social withdrawal. Detachment from your own body, from yourself and society.

This experience of detachment, seeking refuge, and a lack of belonging in the world represents the complexity of the PSW condition that may provide a solution in the short-term, but can give rise to greater physical, emotional, familial, and social difficulties in the medium and long-term.

Discussion of study 2

The purpose of this study was to identify characteristics of PSW individuals and their families as they are perceived by mental health professionals working with this population. Our analysis revealed frequently mentioned characteristics of PSW of which five main themes emerged, including Family Dynamics, Psychological Characteristics, Typical Behaviors, Past Difficulties and Present Challenges

As reported above, some of the most frequent characteristics of PSW perceived by mental health professionals, did not describe characteristics of PSW individuals per se, but rather of their parents and their family dynamics. It is possible that this trend is influenced by the fact that 63% of the professionals in our sample have worked with parents of PSW and hence they are more focused on familial circumstances rather than individual ones.

Respectively, one of the themes arising from the analysis of the professionals’ interviews is ‘Family Dynamics’ as PSW characteristics. The importance of this aspect was already stated by Li & Wong (2015) who have suggested a typology of PSW individuals depending on their overprotective, dysfunctional or highly achievement demanding families. To date, parents’ attributes such as parental psychopathology and parenting styles, like enmeshed parent-child relationships, were mentioned largely in a negative context as contributing factors to social withdrawal (Chan, 2016; Umeda & Kawakami, 2012). However, in the current study we also observed an emphasis by the professionals regarding the experiences of the parents themselves (e.g. helplessness, fear and anxiety), sometimes as a possible explanation for the position they hold (e.g. avoidance), thus enriching the picture of the familial dynamics.

The focus on familial characteristics in the current study may reflect a community-orientation of the Israeli society in general. As a relatively small country that is facing challenges in multiple areas, the concept of ‘mutual responsibility’ is rooted in the culture. In a collective-oriented cultural environment, problems like social withdrawal may be considered as familial and communal and not only individual and treated accordingly, as was previously suggested in other countries with some similar cultural patterns (Sakamoto et al., 2005).

Another two themes that emerged from the interviews focus more on the individual characteristics of PSW individuals, namely psychological characteristics and typical behaviors. While the behaviors of PSW individuals – like spending most of the time at home and avoiding social situations – are apparent and in fact have been suggested as criteria for the definition of PSW (Teo & Gaw, 2010), recently more efforts were made to address also the psychological dimension of PSW. One example is the effort to clarify deeper psychological characteristics of Hikikomori using diagnostic tools like the Rorschach test (Katsuki et al., 2019). However, there is still a lack of reports about the inner worlds and experiences of PSW individuals.

Finally, time is a core element in the definition of PSW (Wong, 2009) as it plays an important role in understanding the etiology of it as a reaction to past events like traumatic experiences (Krieg & Dickie, 2013; Lee et al., 2013; Teo, 2010), and/or as a reaction to present challenges like socio-economic conditions (Wong, 2009). The clinicians in our sample also considered the temporal aspect of PSW as they have pointed out complications which stem from the past (‘Past Difficulties’), as well as challenges in the present (‘Present Challenges’) as characteristics of PSW. Some characteristics that have been mentioned in this study and in previous ones (e.g. psychopathologies) are persisting from the past into the future.

Notably, the themes of characteristics mentioned here are not suggested as poles that mutually exclude each other, but rather as ones that can co-exist in a simultaneous manner. As such, they allow us to learn about the complexity and multitude of this phenomenon, as perceived by the professionals who deal with it.

Conclusions and possible implications

The two studies that are presented here show some of the characteristics of individuals and families that are coping with PSW in Israel.

The first study provided initial empirical support for the existence of PSW in Israel and offered information about its demographic and clinical characteristics. Moreover, it suggested that these characteristics are rather similar to those reported worldwide (including gender, age, duration of social withdrawal, and additional psychiatric diagnoses).

The second study provided the perspective of professionals who are dealing with PSW on the phenomenon in Israel and identified five broad themes of characteristics.

The integration of findings from both studies suggests a common individual profile of PSW in Israel – mostly men in their twenties with underlying psychiatric issues. However, according to professionals who work with PSW, other characteristics are also very important, including but not limited to familial factors. This was also implied by the fact that 95% of the referrals to the Outreach service in our sample were made by help-seeking parents.

We conclude that PSW, as it is reflected from the current study, is characterized by multiple features in different domains including individual and familial ones. Accordingly, programs for prevention and treatment should address this problem in a broad and multidimensional scope and offer help both to individuals who deal with PSW and their parents and other relatives. This emphasis adds further support to recent studies that focused on familial variables that can potentially improve PSW individuals (Nonaka et al., 2020) and on ways to support their family members (Kubo et al., 2020).

Limitations and future directions

The results of this study should be interpreted with caution due to several important limitations.

First, because OH is the founder and the managing director of the therapeutic service organization through which the information for the study was collected (‘Outreach’), there is a possible bias due to the double role as service initiator director and active researcher.

Second, the sample for study 1 was a convenience sample based on data collected retrospectively from a private therapeutic service, and not collected for research purposes. In such a sample, there may be a built-in bias associated with the type of private service consumers (e.g., their insight, motivation, strengths, means, etc.), as well as potential bias due to self-report. Third, Study 2 relied on a sample of mental health proffesionals who gave an indirect account of their perception of PSW. As a result, it lacks firsthand information regarding PSW individuals’ self-perceptions and experiences. And finally, the significant variability in the relevant experience of each professional should be taken into consideration, given that it ranges from a few cases to a few hundred cases that have been treated in different methods and settings.

Future research on PSW in Israel should use a prospective sample rather than a retrospective one, in order to assess the prevalence of the phenomenon and gain a deeper understanding of PSW characteristics. The hypothesis regarding the connection between PSW and military service in Israel can be tested in collaboration with the army. Finally, to further examine the importance of family dynamics in PSW, more qualitative and quantitative research that explores family members perspectives’ is needed.

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Supplemental material, sj-pdf-1-isp-10.1177_0020764020984192 for The scope and nature of prolonged social withdrawal in Israel: An initial quantitative and qualitative investigation by Or Hareven, Tamar Kron, David Roe and Danny Koren in International Journal of Social Psychiatry