Education Quarterly Reviews

Hikikomori has been recognized as a significant social issue in Japan. It is a Japanese term that refers to young people (aged 18-39 years) who have been in an asocial state of social withdrawal and social isolation for over six months. The Cabinet Office of Japan suggests that the number of hikikomori youth has reached approximately 700,000 and is still growing. In addition, recent surveys suggest that hikikomori has a prolonged influence, such that more than 610,000 middle-aged people (aged 40-65 years) have remained in a hikikomori state which began at a younger age. The major challenge of this issue facing experts is that Hikikomori individuals usually repulse external support or interventions, either consciously or unconsciously. Hence, psychological therapies reliant on external interventions have inevitable limitations in curing hikikomori. Our methodology of C-BED (Community-Based Enterprise Development), on the other hand, has proven effective in overcoming this challenge, based on the results of our pilot study supported by Japanese NGO and TOYOTA Foundation. C-BED is a peer-to-peer learning process in which hikikomori share their thoughts with peers in similar situations through online dialogues. In developing the original program, we adopted the Dialectic Behavior Therapy (DBT) to the C-BED and produced 10 online modules for participants to interact by using online SNS group chat. The results of the online workshops (online C-BED) for five Hikikomori youth suggested that their psychological anxiety has been decreased and their willingness to participate socially has been strengthened after attending a 3-course module. In addition, C-BED has incomparable advantages in approaching hikikomori in remote areas at a meager cost, and in bringing positive changes to those who are struggling with psychological problems, no matter their cultural or economic backgrounds.


C-BED Approach and Achievement
C-BED (Community-Based Enterprise Development), a tool produced conjointly by the Japanese Ministry of Health Labor and Welfare (MHLW) and International Labor Organization Bangkok (ILO), pioneers an innovative community development methodology, which introduces a series of workshops among the vulnerable population without trainers or external intervention. The training guidelines and modules are available online as open-source downloads, in order to allow for global availability for any user. The methodology was initially designed to help entrepreneurs and business owners plan and improve their enterprises. The defining features of C-BED are its peer-learning concept and low implementation cost. As a result, C-BED can be easily customized to suit the needs of different beneficiaries and to outreach vulnerable and remote groups, even with limited resources or capacity (ILO 2019).
Due to its accessibility and low cost, it was hypothesized that C-BED would have considerable potential in treating mental illness. Based on the funding granted by the Japan Foundation in 2015 and the Toyota Foundation in 2016, the author conducted a series of programs and studies with an integrated-methodology to prove the effectiveness of C-BED in addressing mental health issues in different countries, including Poland, Japan, Belgium, the U.S.A (California), Bangladesh, Cambodia, Sri Lanka, and China, over four years. In 2017, another project entitled "International Comparative Study on the Effect of Philosophical Dialogue in Self-help Groups," focused on awareness development in self-help groups using C-BED, was carried out and achieved great success. The author then submitted a report entitled "Self-Help Group Guideline" as a result of the international joint research funded by Toyota Foundation (Toyota 2018). Ahead of this report, the preliminary action-research report on Self-Help Group was submitted to the Japan Foundation in 2016 (Yokoyama 2016), and then to Kyoto University in 2017 (Yokoyama 2017). With the discoveries and practical outcomes, these projects were selected by the Ministry of Internal Affairs and Communications of Japan as one of the top 100 teleworking pioneers in 2016. In 2018, the author compiled some of the findings in a doctoral dissertation entitled "Dialogue in Self-Help Group" to the Graduate School of Advanced Integrated Studies in Human Survivability at Kyoto University, Japan (Yokoyama 2018). During this process, in 2016, C-BED project members from Japanese MHLW and ILO Bangkok were invited to a conference held by Toyota Foundation project in Phnom Penh, Cambodia. The conference, which was attended by upwards of 10 NGOs and two international organizations, acknowledged the initial development of C-BED and the implementation for youth self-help groups in a variety of countries.
The C-BED programs described above have had a long-lasting, positive impact on subjects with better-thanexpected performance. The community users of C-BED in three cases continued to build online connections through online SNS, carrying out peer-learning activities through video communication spontaneously and consistently, several months after the project ended. In particular, the methodology has proved to be effective in solving life problems such as limited job opportunities, poverty and gender-related discrimination faced by Muslim women (Chams) in Cambodia and Bangladesh, and with young people in countries of middling development. C-BED. Furthermore, in Poland, it has been found that online C-BED has a significant impact on unemployed youth with online-game addiction. Drawing on these results and experiences, we started to explore the possibility of curing hikikomoris in Japan utilizing C-BED from June 2018. The team conducted an online pilot workshop with five hikikomoris in 2019. The following sections will discuss the background, methodologies, and results of the study in detail.

Hikikomori Issue in Japan
The hikikomori phenomenon in Japan has raised great concern among social activists, governments, and the media, amongst others, who have suggested that it represents significant crises in youth public health, social integration and economic activities. According to the data from the Cabinet Office of Japan, the total number of hikikomori youth who are NEETs (Not in Employment, Education or Training) has reached 710,000 (White Paper on Children and Young People, 2018). Other sources estimate that this number may have exceeded 1 million (Zielenziger, 2006). Hikikomori individuals usually have a complex psychological disorder of compounding social anxiety, high levels of inferiority complex, assumed competence and escapism.
Social Anxiety: A long period of social isolation can cause strong anxiety and disturbance in personal relationships. For example, in many cases, these young adults tend to have barriers in correctly interpreting others' behaviors as they lack enough social experience. In many cases, they are not able to recognize social roles or grasp a sense of their own social role, such as being a 'student' or being a 'worker'. Yokoyama (2018) suggests that the cultural peculiarity of self-negation in Japanese spiritual culture is related to 'a sense of oneness' between society and individuals. This symptom occurs because individuals with low self-esteem and high self-negation are hypersensitive to others. This hypersensitivity may lead to a failure in building relationships and in obtaining selfaffirmation from social recognition. This psychological tendency causes "self-stigmatization" to become deeply rooted during their adolescence. Scopophobia in public, such as on a crowded train, is a typical symptom of social anxiety. Usually, the young people who are suffering from scopophobia have a constant state of heavy selfcriticism and self-dissatisfaction. Hence, they develop 'general negativity of others' as a view towards them and misinterpret others' behaviors as aggression or negative expression.
When parents or schoolteachers impose their own value standards on adolescents, the adolescents are inclined to internalize these general standards into their own value-system. With this 'internalization of others', value judgement causes the young person to negate herself or himself when the ideal status does not match with her or his reality. Furthermore, with a stubbornly fixed value system, the children also tend to become disrespectful and detrimental to others, as a result of judging themselves by these internalized standards. Due to this judging tendency and stereotyped discrimination fostered in childhood, uncontrolled emotions dominate the youth and can trigger acute anger and emotional explosion, expressed by words and behaviors which instigates their inferiority complex. For instance, if the parents disrespect low-waged workers, their children may also look down on people who work for a lower salary, exposing themselves to self-criticism as they are often also. It becomes especially problematic when these tendencies result in a severe state of prolonged isolation and poverty as an adult, often referred to as the '8050 issue,' which indicates 80-year-old parents supporting their 50-year-old children. Nevertheless, the Japanese government and NPOs have been providing various types of supports for more than 10 years, including third-place provision, job counselling, psychological treatment, housing and workshops. The young person will often reject these support and counselling services that make him or her confront their feelings of inferiority. Thus, when the youth is not able to observe their own psychological difficulties, they will be trapped in an inferiority complex, and social disabilities manifest through fastidious and unpleasant behaviors toward others, causing them to be social excluded and isolated in the end.
Addiction caused by escapism from the reality: The long-term, jobless isolation deteriorates the youth's mental health, making them inclined towards addiction to online games and internet surfing in many cases. Virtual reality and society in online games or similar online services provide them with an opportunity to communicate and interact with others as if it were real life. The virtual reality enables hikikomori to escape from reality, and it makes the youth more dependent on the internet or game. However, when parents give criticize the youth for playing online games, the children will feel 'guilty' about gaming even though it is what they like to do. Gradually, they consider what they enjoy and want to do as wrong. The days hooked on the game strengthen their guilty feelings, bringing self-negation in addition to discordance with family members.
Due to the above reasons, the youth choose to be isolated, rejecting others including family members, as the result of their resistance against an abstracted value system of family and society. Even after getting out of hikikomori state and regaining connection to society, the suffering from a long-term hikikomori often causes individuals to be highly dependent on social security or pension for disability in most of the cases. Once social security is no longer available, the youth becomes homeless after their parents' death. One shocking news story reported that a mother living with her daughter in Hokkaido district starved to death without any social supports and remaining isolated in her house in January 2018. Without an effective method of identification and treatment, hikikomori has been becoming chronic, leading to an eminent social problem named '8050 problem,' which indicates a household in which parents in their 80s live with their sons or daughters who are in their 50s without income. Finally, the state of hikikomori and the fear of it can lead to violence in extreme cases. In 2019, a father killed his own son, who was hikikomori, after becoming convinced that the son would kill kindergartners (Sankei 2019). This case occurred after the Japanese media broadcasted a case of indiscriminate murder against primary school students committed by hikikomori in Kawasaki district. To make things worse, the cases above and other serious cases enlarge the negative image of prolonged hikikomori in society in TV broadcasting and internet news. The image brings about reflexive self-stigmatization when the parents and youth identify as hikikomori. This stigmatization also pressures the hikikomori family, who are ashamed of their son or daughter, also suffer from an inferiority complex by hiding their issue from neighbors, resulting in negative spirals and moral panics in Japan. Thus, to a greater extent, uncritical journalism and societal gossip have been exacerbating hikikomori problem in Japan.

The difficulties and limitations of the existing psychological treatment
As mentioned in the previous section, the biggest challenge in approaching the youth in social isolation in Japan lies in limited accessibility of external support. In the U.S.A, more impoverished households were found to be more likely to resist authority and reject welfare support in the 1950s. Similarly, the essence of the recent social problem in Japan can be found in an ignorant cognition: those in the most need are the most likely to reject help. Even though there are plenty of policies and social resources for supporting people in social isolation and poverty, isolated citizens do not try to utilize them. When hikikomori does seek help, social workers may recommend the youth see a psychiatrist and receive mental disability or developmental disorder certification in order to prevent from being homeless. This treatment, however, ironically has resulted in an increasing number of alleged psychiatric misdiagnoses in Japan, where citizens have not enough opportunities to receive psychoeducation in order to avoid the risk of institutionalization (Yoneda, 2018). Nowadays, a growing number of the youth are become addicted to drugs and have fallen into apathy after being diagnosed as a hikikomori. In some cases, self-help groups have formed to support parents whose children are apathetic due to the side effects from the limitless prescription given by psychiatrists. Inherently, there are issues regarding human rights violation, poor understandings of how to support adolescents in decision-making, as well as inadequate medical education accessibility (Yoneda, 2018), which has been serious enough to be reported by the United Nations in 2019 1 .

Research Design -introducing C-BED to Hikikomori care
Different from expert support and external interventions, the peer-to-peer learning concept of C-BED enables young people of similar social status and common feelings to get together, creating a comfortable environment for them to interact and communicate without any medical authoritative/hierarchical relationships. It overcomes the disadvantages of external intervention, psychological barriers and other environmental difficulties for hikikomori. Alterations to the original C-BED were made in order to make this program more suited to the needs and wishes of hikikomori. Firstly, this project adopts text-dialogue with online-group chat, which is popular among the young people. The text-dialogue aims to dispel the social anxiety and interpersonal fear. Secondly, the modules adopt Dialogical Behavioral Therapy (DBT) after learning of the practice through the Mental Health America (MHA) California, Project Return Peer Support Network, who participated in the joint-research project funded by Toyota foundation in 2016. Kawasaki, an author of this paper, analyzed the DBT, selected frameworks which are meaningfully adaptable and incorporated them into the modules.
Based on the analysis, we consider hikikomori as a habitual reaction from an interaction of social environment and individual consciousness. The reason for its prolongment incorporates multiple factors, which means that every individual has a different recovery process.
The most effective approach that manages this psychological uniqueness is called a "recovery" model advocated in the mental health discipline. One of the hikikomori self-help groups in Japan has reported this method's positive effect (Warita et al., 2016) on the hikikomori youth. "Recovery" is a concept which focuses on self-realization. It does not regard the symptoms of mental illness as the object of being cured but as a unique individual reaction to the environment. Along with this recovery philosophy, the individual who struggles with psychological or mental difficulty is envisaged to have a holistic personality in the process of a unique life, instead of a fragmented human being as a patient with a specific sickness or difficulty. The recovery process attempts to repair human relationships with this vision of self-realization against self-stigmatization. This concept was originated by the MHA.
The author of this report, Yokoyama, spent a week interviewing 9 members of MHA to study on the practical implementation of recovery policy. The findings suggest integrating DBT with Motivation Interviewing (MI; Miller 2002), a method which provisions non-hierarchical relationship and welcomes open questions enabling free talking between counselor and patient (literally it is not therapy but interviewing) at the implementation phase. The integrated approach is the practically embodied methodology of recovery.
For the above reason, this project adopts DBT with MI in developing the modules. The details will follow in the next section.

Method
As shown in Table 1, we developed 10 C-BED modules targeting hikikomoris. Due to the time limitation, we only used #1, #5 and #10 in this action research. The tests were conducted once every two weeks (8 pm to 9: 20 pm on the 9th, 16th, 24th February 2019, respectively) through online group meetings. The study was designed and facilitated by Taizo Yokoyama, Akira Kawasaki, and Tomoe Mitsumiya.

Test Process
1. Finding participants in Self-Help Group (5 participants expressed interests) 2. Contacting individuals through e-mail or phone 3. Forming a group-chat for the pilot and inviting the testers 4. Implementing the pilot C-BED 5. Conducting follow-up interview surveys through e-mail or phone two times (one month and three months after the pilot study respectively)

#2 Learn how to avoid denials
Understand the feeling of being in denial; forgiving and permitting different value judgement, accepting diversity of opinions in addition to practicing not the negation of others, but keeping a positive attitude.

#3
Observe yourself Practice "the ability to observe the mind/ consciousness" and consider what makes you happy and feel good.

#4
Deal with inferiority complex Accept imperfectness; as there are no perfect personalities, the others have weaknesses as you do, allowing imperfectness.

#5
Learn that people can change Realize all the personalities and properties change constantly in time and environment, including one's own.

#6
Get rid of your frames Stop thinking "I can't change anything because I was born like this" and convert to "change myself", getting rid of the fixed framework.

#7
Dissolving stress Learn DBT skills through exercises to mitigate stress in daily life.

#8 Control your emotions
Acquire capacity of controlling your emotion by having a bird's-eye-view of yourself and sorting emotions along with the list of emotions (DBT).

#9
Communicate smoothly Study the skill for sustainable relationships, balanced with selfrespect.

#10
Think of your next step Realizing that small steps build up to a big goal, setting vision after C-BED.

Participant (Subject) Characteristics
Five hikikomoris living in Osaka, Kyoto, and Nara prefectures participated in this online-C-BED pilot project. All the participants are mobilized through the Self-Help Group in Osaka. Furthermore, the participants are informed of the project concept by telephone or e-mail and consent to test the modules under the condition of anonymous participation. All the modules are translated into Japanese and distributed to the testers before the C-BED workshop. Smart phones were used as a communication device among the participants (one of them borrowed her mother's phone). Therefore, the project platformed the social-networking service with mobile application in Japan.

Results
The five participants' status before/ after pilot C-BED is shown below.
＊When the participants answer that positive change has occurred after C-BED in the follow-up survey, we marked P (positive) in the chart. When they answer no change or if they dropped out during the pilot, we marked N (negative) in the chart.

Key Findings -at the development stages-
We found the successful factors ascribed to the following features, in addition to the lessons learned during the experiment.

Concerning Mobilization phase
The most challenging stage of the C-BED is at the mobilizing phase. Especially for hikikomori in this project, as the focal issue is 'social-relationship', mobilizing action itself connotes supportive care to the expected participants. For instance, in targeting youth in online-game addiction with family problems and so forth, there should be connections and partnerships with social/public services, ideally multiple stakeholders. From this regard, self-help group formation with support agencies is supposed to be the best methodology to lead this online approach. Moreover, in Japan, the Support for Livelihood of Needy Law (Sei katsu Konkyusya Jiritsu Shien), which was legislated in 2013 and began its implementation in 2015 as a second national safety net, is envisaged to be linked with this project attempt.

Taking advantages of case-study in developing modules
We aimed to create a relaxed atmosphere to let the participants open their hearts to other unfamiliar members and to enable free text-dialogues. Also, we set our team goals to "bringing a change in daily life", "introducing a new habit", and "achieving meaningful vision-setting" in this pilot project.
When selecting three modules from the total of ten modules which we developed, we carefully avoided some types of activity which might directly recall the past traumatic experiences in testers. At the same time, we also refrained from any treatment and assumption of the participants as 'patient' or 'problematic' population. Even though we paid attention to this perspective in advance, one participant complained after the first module about an activity which seemed to request her to reflect on her experience and which triggered negative personal emotions.
After reviewing the feedback mentioned above, we considered whether the second and the third modules should have case studies at each initial session. Case study works well in the project because it provides reflection and change in consciousness in the process as well as fostering objective thinking about the situation, allowing for some distance from personal experience. Despite plenty of contents which appeal to emotions and thinking of participants in our prepared ten modules, it turned out that the case study is the best formality to enable smooth and natural dialogue among the participants.

Concerned period and length of the modules
A lengthy workshop could result in imposing psychological burdens on the mentally vulnerable youth. In this pilot project, we held workshops once a week for three weeks. Female D dropped out after the second module and gave feedback about the time length of more than 90 mins. Receiving this feedback, we modified the content and shortened the third module into 60 mins.

Introducing mindfulness/ meditation
At the beginning of each module, we introduced mindfulness meditation for 5 minutes, which plays a key role in DBT. In order to signal the end for testers, we utilized the video navigation by sharing the link in group chat. According to our follow-up surveys, one of the participants, Female B, made it a habit and incorporates into her regular exercise.

Introducing challenge task
Taking advice from MHA, we introduced a session of a "challenging task" from the beginning. The session navigated the participants to determine "a new life habit" and report daily achievements to the group chat. To avoid too much pressure on testers, we set the challenging task as a voluntary option. However, the participants reported a task for only two days after the first module, and we failed to make it become habitual. In future programs, there ought to be another mechanism, and an incentive could help strengthen this system.

Discussion -key practical recommendations -
This pilot project demonstrates how an online version of C-BED (text dialogue) works effectively, and how it can help change and influence the youth who live in an isolated situation. This attempt also unlocks a way to empower (1) marginalized populations with culturally limited social participation, like Muslim women, and (2) people living in isolated or remote areas (e.g., mountain areas or islands) with available Internet access. It envisions a new empowerment methodology with a relatively small budget, suitable for both developed or developing nations.

Target habitual / behavioral change for entrepreneurship
The advantage of online C-BED is 24-hour accessibility and that it encourages participants to report, post (voicing), and to smoothly exchange their ideas and opinions. Furthermore, online C_BED may bring alternative way of thinking to the subjects. The online relationship does not require physical commute, and this feature is suitable to establish a third place in their busy daily life. Because people in poverty usually have difficulty finding the chances to participate in educational seminars and workshops offered by development agencies and facilities, the portability and accessibility of online C-BED will doubtlessly work for them.
However, the modality of online workshop is, in both positive and negative ways, a distinctive form compared to the ordinal face-to-face session. It is difficult to achieve multiple objectives in cognitively limited text workshops.
In other words, online interaction should not be the main agent of human-support approach; yet, it works well as an alternative and accompanying instrument which brings human interactions directly in reality. Therefore, targeting habitual or behavioral change is a moderate step to initiate a relationship with the participants, helping them to grasp the concept of C-BED.

Considering time-requirement in text-based activities
Long, text-based activities cause fatigue and stress in the participants. One module should be compacted to, at most, 60 mins. Also, every workshop should reserve 5 minutes for smart-phone users who take more time to type than computer keyboard users. The dialogue activity, which attempts to motivate and facilitate opinion exchange, requires 15 minutes minimum to deepen the discussion.
In addition, the question and required task must be clear so that anyone can understand and participate in the discussion in the chat. The program must prepare a technical manual which explains how to operate the application in smartphone. For instance, this pilot project tested the chart-fulfillment in paper to gather visualized answers from the participants; however, most of them had trouble understanding how to do this, such as how to take and send pictures. A prepared description or technical manual document, such as pictures or video interaction, should be shared in advance. At an initial stage of the online interaction, simple open-ended questions work better to facilitate participants to understand the concept of C-BED.

Case-Study based, consistent module
With adequate case studies, the activity works well in eliciting individual value judgement and opinions, and letting the participants express a unique personality in a relaxed mood. The module development should simplify every activity and connectivity between activities and modules: for instance, after introducing their 'ideal working places' in future, next activity should contain a topic related to it. Topics and themes of dialogue ought to be made very clear by establishing guidelines and examples of the expected answers in activities that the participants can reply with 5W1H. In addition to the individual digital task, physical activity may encourage more motivation, for instance, writing a diary, interviewing people, sketching a scene in life, researching on certain topics, presenting the findings and opinions in the video, and reporting the progression of change, to name a few. From this perspective, tsudurikata (writing) education, a unique, writing-intensive educational movement in pre-and post-War Japanese social education, should be reexamined with regards to its approach to psychological development and empowerment through active learning for adolescent youth.

Fun and Re-creation oriented
Follow-up surveys suggest that the participants are looking for more 'fun' in interaction, and at least demand on 'to notice' in activities. In addition to the equality amongst participants, the flat relationship between organizer and participants elicits new perspectives and valuable change for all the related persons. The interaction through dialogue can also delimit the goal of online C-BED. When this goal gets achieved, the change is also more beneficial for all.
With regards to the amusement modality, from a more micro, technical aspect, online text-dialogue permits funny stamps, private pictures, and chatting exchanges, which can be part of the interactions required to re-create their life with human relationships. Incorporating "fun" should be a core value in developing online C-BED.
Our pilot modules were overambitious given the limited sessions. After all, interestingly, and regrettably to some degree, the follow-up surveys found that 'the most exciting activity' for the participant was an initial self-introduction regarding, for example, personal hobbies. Such casual interaction would be enough to bring a small change, which may lead to bigger changes in personal life.

Possible web-based platform
An online platform would design a meta-field of online C-BED which allows the participants to view the developed modules and feedback from other users who experienced the same C-BED, as well as to mobilize the workshop partners and members spontaneously. Construction on such community in the web platform makes C-BED more familiar to their interests, and it would also resolve the challenge in mobilizing phase. The first expected task in the possible construction of the platform is to draft the guideline for the participants, as well as depicting the developer's visions.

Introducing Video/ Movie technology
This pilot adopted online videos to explain mindfulness meditation to the participants. If it does not diminish the active learning of the participants, video instruction and input could play a broader role through audio-visualized lessons, combining well-controlled e-learning and communication with peer-learning. For instance, instead of the case-study written in text, movie and audio materials could play a more intuitive role in peer-learning. With a view towards smooth facilitation and functions of such online-based learning, an adoption of multi-cognitive media should be considered in developing more appealing tools of human development for potential users of C-BED.