Fiorenzo Ranieri
Recently, I came across two interesting doctoral theses submitted at the Tavistock & Portman NHS Foundation Trust: Shut in and cut off? by Petra A. M. Mohr (2019) and Socially withdrawn young people by Margherita Urani (2023). Both studies offer an in-depth psychoanalytic perspective on voluntary self-seclusion, drawing on interviews with child and adolescent psychotherapists who have worked directly with hikikomori patients. The two theses provide a rich source of information about patients’ behaviours, experiences and mental processes. The therapists interviewed describe their clinical experiences, the patients’ subjective states, and the complex countertransference dynamics that emerge in therapeutic work.
Mohr’s thesis stands out for the depth of its analysis: it explores the inner world of withdrawn young people, characterised by emptiness, emotional numbing, and a wish for psychic disappearance. The therapist is often experienced as an intruder, but also as a silent witness capable of withstanding attempts at expulsion. Urani, on the other hand, focuses on the therapist’s role as a “good object” able to provide a stable mental presence even when the relationship is denied or attacked. Both theses offer an emotional and relational map of therapeutic work with hikikomori patients, an area rarely explored in such detail. They are valuable sources for anyone working in the fields of adolescence, social withdrawal and psychoanalytic psychotherapy.
The main themes addressed include:
Social withdrawal as a psychic defence: both studies interpret hikikomori as a form of “psychic retreat” (Steiner), a defence against relational anxiety and dependence.
Patients’ mental processes: Mohr in particular explores the inner world of withdrawn young people, describing experiences of emptiness, emotional numbing, and a wish for a state resembling “psychic near-death”.
Countertransference: both theses devote considerable attention to therapists’ emotional responses — frustration, helplessness, anxiety and claustrophobia — both as tools for understanding and as clinical challenges.
The role of the therapist: from Mohr’s “silent witness” to Urani’s enduring “good object”, the therapist is called upon to tolerate attempts at expulsion and the denial of the relationship, while continuing to offer a stable mental presence.
Some passages from Mohr’s research struck me as particularly interesting. I reproduce below a few excerpts from her work.
Therapy bocomes psychic retreat
Several interviewees described how they, at times, questioned whether the therapy itself had become drawn into the withdrawal system of the patient. For example, Andrea described how her patient’s obsession with the computer world made her feel so shut out that the therapy itself seemed to have succumbed to a retreat inside the computer world.
“I often felt he tried to reproduce this solitude in the room with me and sometimes he related to me as if he was by himself with the computer […]. He would just go on and on and on, ten, twenty minutes talking about computer things, using a very technical computer language. I told him that I’m not acquainted with this language and I asked him to explain initially […], but after a while I realised it was not really the meaning of the words; it was more a way to disconnect.
So the way he communicated was to block you out?
Yes to block me out and to (tries to find the words..) really (blows out) you know, to really (blows out as if frustrated), to continue to be isolated in a way, to stop the possibility to engage in any way in relation to me. Um, and in the initial period of the treatment I felt that this was really his anxiety, anxiety of being in the room with someone else. […] But as he became more used to me I think he was getting more comfortable, but he would still from time to time resort to this sort of, this sort of: this place of his own, his own mind, really disconnecting, and going on talking for hours about computer games, or some (blows out) using some technical terms in creating computer games and things such as these. And I often found that thinking about the symbolic meaning behind this story that he was creating was not really the point, not really helpful, it was more a way of communicating these states of… isolation”.
Andrea became increasingly frustrated while she told me this. I wonder if this sense of frustration originated from a feeling of exclusion. Here she is, trying every effort to engage with this person, to understand what he is talking about, while his mind instead is linked with the computer, using technical language the therapist doesn’t understand, effectively excluding her. Lingiardi (2008), working with a patient who used cyberspace like a psychic retreat, describes how she used to feel in competition with the computer and had to tell herself that a computer cannot feel pain and thus is incapable of reverie, of transforming projected emotions.
Looking at this through a framework of projective processes, Andrea’s frustration here could be thought of as holding and transforming projected emotions that the patient had communicated: feelings of exclusion, disconnection and isolation. The sense that the therapy had become another form of retreat became one factor in Andrea’s decision, following discussion with her supervisor, to end the treatment after three years.
Lack of self-care
“She felt herself to be very unlovable, uninteresting to both of her parents. I think that comes into the session as well, her self-care can be very poor, she would wear tatty clothes, she makes herself unappealing”.
Julia
Five of the therapists described their patients as not looking after themselves and, as the above quote from Julia suggests, presenting an unkempt appearance. Not looking after themselves might be an external expression of not feeling cared for internally. Julia thought that her patient’s withdrawal was partly due to a re-enactment of childhood experiences of neglect.
“[She was] so angry against her mother that she wrecked herself, and then ironically replicated, re-enacted the situation where she would be left to rot in her flat, but now it had become something that she had engineered”.
In a mechanism described by Anna Freud (1936) as identification with the aggressor, a powerless, passive state of being neglected as a child is turned into an active state of self-neglect. The neglectful object in reality has become internalised and now, as an internal object, exerts its influence. By making herself unappealing, Julia’s patient communicates how she feels inside: uncared for and neglected.
These two studies, although different in style and depth, complement one another. They offer both a clinical and a human perspective on the hikikomori phenomenon, placing at the centre not only the withdrawn young people themselves, but also those who accompany them through the difficult therapeutic process.
References
Mohr, P. A. (2021). Shut in and cut off? An exploration of internal and external relationship dynamics of adolescents and young adults who are socially withdrawn and isolated in their home (Doctoral dissertation, Tavistock and Portman NHS Foundation Trust/University of East London). http://tavport.eprints-hosting.org/2524/1/Mohr%20-Shut.pdf
Urani, M. (2024). Socially withdrawn young people: how do child and adolescent psychotherapists understand and experience working with them in a London mental health context? An interpretative phenomenological analysis (Doctoral dissertation, University of Essex & Tavistock and Portman NHS Trust). https://repository.essex.ac.uk/38667/