Indirect Psychotherapy With Parents of Adolescents and Young Adults With Hikikomori

Fiorenzo Ranieri

The journal Psicologia Clinica dello Sviluppo (Il Mulino) published the article “Indirect Psychotherapy With Parents of Adolescents and Young Adults With Hikikomori” in its first issue of 2026 (available in Early Access at the following link: [link]). The pre-print version submitted for peer review is reproduced below.

Abstract:

This article presents a psychodynamic approach to working with families of adolescents and young adults experiencing hikikomori, a specific form of extreme social withdrawal. Young individuals with hikikomori present sensitive challenges for mental health professionals, particularly when they refuse direct contact with clinicians. In such cases, therapeutic work with the parents often becomes the only feasible intervention. The method of indirect psychotherapy is a parent-focused intervention that respects the adolescent’s refusal of treatment while aiming to redefine relational dynamics within the family system. This process seeks to establish an alliance with the parents and gradually engage them in confronting the often idealized yet emotionally neglected internal object of the “child.” When effective, this approach can catalyze meaningful changes in the family and, indirectly, in the adolescent. The article concludes with the presentation of several clinical vignettes.

Keywords: indirect psychotherapy, parent-focused intervention, hikikomori, psychodynamic therapy, psychic retreats

Introduction

This article arose from an attempt to explore the emotional experiences and relational dynamics within families in which an adolescent manifests social withdrawal, particularly a refusal to leave the home in the absence of a formal psychiatric diagnosis. While social withdrawal is well documented in clinical psychopathology and is often regarded as a symptom occurring within various psychiatric conditions (Morese et al., 2020), a growing number of adolescents appear to withdraw not because of schizophrenia, autism spectrum disorders, intellectual disability, or major depressive disorder, but for reasons that escape traditional diagnostic categorisation (Ranieri, 2018).

The term hikikomori, borrowed from the Japanese clinical literature and now included in the DSM-5-TR (APA, 2023), denotes a distinct phenomenon of prolonged and voluntary isolation. A growing body of research has investigated hikikomori as a culturally influenced condition with global relevance (Li & Wong, 2015; Neoh et al., 2023). An interesting perspective proposed by Kato et al. (2019) suggests that the hikikomori phenomenon lies along a spectrum ranging between psychiatric and non-psychiatric states.

Clinical accounts often describe young people with hikikomori as showing an early symbiotic entanglement with the mother, while the father remains emotionally marginal. This persistent maternal fusion hinders the adolescent’s capacity to separate psychologically and develop an autonomous identity (Krieg & Dickie, 2013). Takeo Doi’s (1973) concept of amae — the desire to depend indulgently and childishly on another person — is particularly useful in understanding the primary relationships of the future socially withdrawn young person. Some authors interpret the adolescent’s hikikomori condition as an extreme and regressive clinging to the mother, a rejection of adult autonomy and objective reality (Hairston, 2010). Others argue that self-imposed isolation represents a belated and unconscious appeal for an amae that was denied in early childhood, when the caregiving environment was experienced as emotionally cold, instrumental, or neglectful (Bowker, 2022).

Indirect Psychotherapy with Parents

Although recent studies suggest that early family interactions may already reveal warning signs of future withdrawal (Ranieri & Monticelli, 2023), families usually experience the adolescent’s sudden isolation as a shocking and disorienting event. Parents often describe their child’s withdrawal into the bedroom as abrupt and inexplicable, a clear discontinuity from earlier developmental stages. In many cases, during previous phases of the life cycle, the adolescent had been the focus of intense narcissistic investment by the parents. The adolescent’s metamorphosis reverses the dynamics of dependency: from being the protagonist of parental redemption or the fulfilment of unexpressed ambitions, the adolescent becomes a child to be cared for, fed, and hidden.

For the adolescent, withdrawal is accompanied by unbearable shame. The gap between the adolescent’s present condition and the family’s expectations becomes psychologically intolerable. Self-confinement is a tragic appeal for relational intimacy, monstrously distorted by inner conflict. Shame soon overwhelms desire, transforming it into self-disgust. The attempt to be seen thus fails. Psychic withdrawal is not a symptom of apathy, but a sign of unbearable internal states against which the adolescent defends himself or herself through self-confinement (Iwakabe, 2021).

Therapeutic work with adolescents with hikikomori and their families is complex and frequently requires a multidisciplinary approach. Like other adolescents experiencing severe emotional distress, adolescents or young adults may refuse direct contact with mental health professionals. It therefore becomes important to develop intervention models involving work exclusively with parents (Trevatt, 2005; Jarvis, 2005). Work with parents can lead to significant changes in family dynamics, which in turn reverberate within the psychic life of the withdrawn adolescent, even when the young person remains outside the psychotherapist’s consulting room (Novick & Novick, 2011).

The model I adopt draws on concepts previously described as “psychoanalysis without the patient” (Modigliani, 1981; Carbone, 1992) or “indirect psychotherapy” (Carbone, 2016). The theoretical foundation of this approach rests on the hypothesis that the child’s primitive fantasies and projective identifications, initially directed towards the parents, can be modified through an authentic transformation in the parents’ own mental representations and emotional functioning (Carbone, 2005).

This work is by no means simple. Parents often arrive in therapy in a state of profound distress. In some couples, this suffering is shared. More frequently, however, a split emerges: one parent resists seeking help, minimising the child’s withdrawal and defending it as temporary or benign; the other parent, by contrast, may be overwhelmed by anxiety and adopt controlling or even coercive strategies, sometimes culminating in open and even physical confrontations with the young person. These polarised positions often reflect long-standing family dynamics that may both have roots in the primary relational environment, particularly maternal enmeshment and paternal emotional disengagement (Ranieri & Luccherino, 2018).

The therapist’s initial task is to recognise and contain the suffering of both parents, whether it manifests itself through denial or hyperactivity. In this way, dignity and meaning are attributed to the experiences of both parents (Rustin, 2018). This shared recognition can establish a minimal common ground on which the couple can begin to collaborate within the therapeutic space.

A second essential task is a psychoeducational intervention that explains the hikikomori condition using accurate and non-judgemental information drawn from both the clinical literature and the therapist’s experience. Parents often have divergent narratives concerning their child’s behaviour, driven predominantly by painful emotional experiences. Neutral, fact-based information can mitigate projections that portray the young person as bad or simply “lazy”, offering instead the perspective of behaviour serving as a defence against unbearable anxieties.

A crucial step is to help parents understand that their child is not simply oppositional but is attempting to protect himself or herself from intense inner turmoil. The young person’s bedroom has become a “psychic retreat” (Steiner, 1993), a space that is both concrete and symbolic, protecting against fragmentation, loss of self, and catastrophic states of mind. When parents are able to grasp this dynamic process, they often begin shortly afterwards to report subtle changes at home: a somewhat calmer family atmosphere, moments of dialogue, and a reduction in tension.

From clinical observation and parents’ accounts, adolescents with hikikomori appear to experience intense feelings of guilt and, at the same time, resentment towards their parents. Although they perceive themselves as a burden or a source of distress, they also feel deeply emotionally hurt. Knowing that their parents are receiving therapeutic support may offer the adolescent a form of vicarious relief, a sense that something is being repaired (Pietropolli Charmet, 2000; Lancini, 2007).

Over time, the focus of the sessions often broadens. Discussions may come to include the couple’s relationship, siblings, the whole family, and everyday life. Interestingly, significant changes in the adolescent — such as taking part in family meals or resuming contact with peers — are frequently reported incidentally, as though they were of marginal importance. Yet these changes often signal the reactivation of developmental processes that had been frozen by social withdrawal.

When indirect psychotherapy is effective, parents develop a greater capacity to mentalise their child’s internal state and to tolerate the ambiguities and limitations of the hikikomori condition. This increased reflective capacity often catalyses significant changes not only in family dynamics but also in the adolescent’s possibility of reintegrating into relational and developmental life. In the following sections, I illustrate this process through several clinical vignettes.

Vignette 1

The parents of G, a thirteen-year-old boy, urgently request a psychological consultation after he has stopped attending school for approximately three months, beginning during the Christmas holidays. The following is a summary of our first meeting.

The parents report that communication with G seems to have broken down. He spends most of his days shut in his room, playing online games with peers. The only social contacts he has maintained are connected with sport: G regularly attends volleyball training.

The event triggering his withdrawal appears to have been related to conflicts with his Spanish teacher, who allegedly pressed him rather abruptly to complete his assignments. In his other subjects, G is a high-achieving student. Following this episode, his school attendance progressively declined until it stopped altogether. In the morning, G pretends to get ready to go out, asks one of his parents — usually his father — to wait for him in the car, but never crosses the threshold of the house. His parents describe this daily ritual as painful and frustrating.

They then report that G appears to have suffered greatly following the distancing of a long-standing friend whom he had known since childhood. It is a void the boy has been unable to fill. His classmates have shown no signs of closeness during his absence, reinforcing his sense of isolation. By contrast, his involvement in sport represents a vital and meaningful space. Other social commitments, such as catechism, have been abandoned.

At home, his parents report considerable difficulty in involving their son. G isolates himself, frequently skips meals, and has refused to attend the consultation with the psychologist. The school has recently informed the family that, because of his absences, G risks not being admitted to the final middle-school examination. This information produced a temporary reaction, with G returning to school, followed, however, by another interruption.

During the consultation, his parents describe G as having once been a cheerful, sociable, and motivated child, both in relationships and in his school performance. Despite his current withdrawal, he has expressed an interest in continuing his education, independently choosing a technical secondary school and particularly appreciating its practical laboratories. His choice was not influenced by his classmates.

The parents report feeling lost and unable to understand their son’s experience. I propose a course of psychological work with weekly meetings to explore family dynamics and understand the possible functions of the withdrawal. I suggest that G may experience a profound sense of shame even in response to minor failures, and that immersion in online gaming may represent a reassuring strategy for rebuilding a sense of competence and belonging.

I also formulate the hypothesis that relational withdrawal had already begun in a disguised form within the school environment, where G may gradually have constructed a kind of “bubble” around himself, becoming emotionally unavailable even before formally ceasing to attend school. Shutting himself in his room appears to be the continuation of an isolation that had already taken place psychically.

I tell the parents that contact with the clinic could also develop gradually, perhaps beginning with an online meeting, as had already happened with other adolescents in similar situations. I introduce the term hikikomori to open a shared reflection on contemporary forms of expression of distress among young people. The mother, who until then had remained restrained, openly expresses her anguish. I acknowledge these feelings of distress and emphasise how frequently such behaviours occur among adolescents and how useful it is to address them without assigning blame.

We conclude by arranging another appointment. I invite the parents to answer any questions their son may have about the consultation, making it clear that, for the time being, he does not need to attend.

Following this consultation, I meet with the parents for approximately three months. Unexpectedly, after about ten sessions, G asks to take part in a session with his parents and subsequently accepts my invitation to attend psychotherapy on his own. I conclude the work with the parents. After a relatively limited number of sessions, G resumes his education and progressively re-establishes relationships with peers.

Vignette 2

M is a sixteen-year-old boy in a condition of social withdrawal. His father has always cared for him on his own, as M lost his mother at an early age. He has two older brothers, both now adults and living independently. His social withdrawal is almost total: M only occasionally meets some former schoolmates in the afternoon. He left school when he turned sixteen.

After an initial consultation, M agrees to begin weekly psychotherapy. Approximately four months later, however, he decides to discontinue therapy, stating that he is now able to leave the house and intends to return to school. This is followed by a rapid return to social withdrawal. In response to this new phase, I propose fortnightly sessions with his father.

The first phase of the work with the parent is devoted to a shared reflection on the meaning of M’s interruption of therapy and subsequent deterioration. Shared feelings of failure and anxiety about M’s future emerge. We reflect on what social withdrawal might represent for his son. The father reports that, because of family tradition and his own personal history, he has always regarded obtaining a secondary-school diploma as essential for his children. During the sessions, however, he gradually becomes aware of his son’s need to construct an autonomous identity, even when this conflicts with his own wishes and expectations.

As the sessions progress, M resumes some social activities and begins to meet a selected group of friends more regularly. About a year after the beginning of the sessions, M proposes to his father that he start working in a factory, following the example of his older brother. His father agrees, despite knowing that this entails definitively abandoning his education.

During the sessions, we consider the changes in the father’s relationship with his son and reflect on how these changes may have contributed to the progressive overcoming of social withdrawal. M begins working as an apprentice and maintains regular relationships with his peer group. Approximately a year and a half after the first individual consultation with the parent, we agree to conclude the work.

Vignette 3

I met B’s parents during the first wave of the pandemic. We met online, a choice dictated by the urgency of discussing their son, a young adult who had been withdrawn in his room for several months, refusing all social contact.

B is the eldest of three children born relatively close together. He has two sisters. After several years of independence, during which B attended university in another city, he returned home and progressively isolated himself, no longer going out, avoiding meals, communicating very little, and remaining awake mostly at night, immersed in the world of video games. His parents and sisters quietly suggest that this change was caused by a romantic disappointment, although there is no certainty about this. A previous meeting of the whole family with a family psychotherapist, which B had reluctantly attended, did not continue beyond the first session.

During our first online meeting, I propose that the parents begin a therapeutic process of their own, since B has refused any form of direct help. Sessions with the couple continue online for several months. The parents appear involved and focused almost exclusively on their son’s behaviour. Over time, the focus broadens. The personal trajectories of each parent emerge, together with the sibling dynamics developing within a family context undergoing profound transformation, in which every family member is confronting separation and the developmental tasks involved in entering adulthood.

During the following summer, the sessions take place in person. Although B continues to live in withdrawal, his parents describe him as more active within the family. The couple begins to explore the meaning of relationships among family members. Their main goal, however, remains the initiation of individual psychotherapy for B. I therefore propose meeting each of the three children individually online. B refuses, while his sisters enthusiastically accept the invitation. Their accounts offer me a valuable perspective on the emotional complexity of the family system.

In the work with the couple, themes relating to parenthood, guilt, and transgenerational transmission emerge. The mother recalls ambivalent feelings experienced during B’s early years and her difficult relationship with her own mother. The father, by contrast, remembers B’s early years as a period marked by depression and emotional distance. These narratives shed light on implicit dynamics that had affected family relationships from an early stage.

The organisation of the domestic space also appears to play a symbolic role. The family lives in a complex of three adjoining houses built by the maternal grandparents, where members of the extended family lived together: B’s grandparents (now only his grandmother) and their two children. During a session, the mother expresses a sense of injustice regarding the treatment accorded to her only brother, the favoured male child. B’s father describes having often felt marginal within a family context that had never truly welcomed him. In this scenario, I come to understand that B had been invested with largely unconscious expectations of vindication on behalf of the “junior” branch of the family.

As the work progresses, B, although remaining invisible, becomes a psychically present figure in the sessions. The therapeutic bond with the parents becomes consolidated, and new representational configurations begin to emerge. Towards the end of the year, B begins occasionally to join family meals. The couple oscillates between hope and the fear of “ruining everything”. Within this climate of fragile openness, I propose a home visit. I know that B will not participate directly, but I believe that the simple act of introducing a therapeutic function into the domestic space may constitute a transformative action.

When I arrive at the couple’s home, B remains shut in his room. His sisters greet me warmly, and we talk at length in the corridor just outside B’s bedroom door. During the meeting, the parents withdraw to other parts of the house. I have the impression that B may be listening: a “presence through absence” charged with resonance. The sisters talk a great deal, emphasising how much their parents are the ones who need help.

The home visit represents a turning point. In subsequent sessions, the couple seems to have gained confidence. I suggest that B, although remaining outside a direct therapeutic relationship, may benefit from the transformations taking place within the family system.

At the beginning of the new year, B asks to enrol in an expensive online course. Although he abandons it after a few months, the gesture appears to be a first movement towards the outside world. Later, to the family’s surprise, he agrees to work for a short period in his father’s company, going with him to the factory every day. The experience lasts a month but is significant for his parents. When B returns to isolation, they express painful disappointment. We discuss this at length, working on the frustration associated with their need for “tangible signs” of recovery.

A further change occurs when the father decides to become involved in a business owned by his wife’s family. B steps forward to join him, probably aware of his father’s attempt finally to find a role within the maternal family. The young man shows commitment and involvement, identifying with his father’s “challenge” and involving his mother on several occasions. Within a few months, the situation changes. B spends time outside the home, works regularly, and contributes to family life. Meanwhile, his sisters, themselves engaged in processes of separation from the family, occupy their parents both psychologically and practically.

The couple, now focused on all three children, proposes reducing the frequency of the sessions. The meetings become less frequent, allowing greater space for the couple’s more autonomous elaboration.

The father’s attempt to collaborate with the mother’s family business ultimately fails, and B shares his father’s disappointment over the unsuccessful project. At this point, B again asks to work in his father’s company. Placed in a non-privileged position within the business, he begins to “work his way up from the bottom”, travelling to work with his father every day. These shared journeys allow the father–son relationship to deepen as never before.

During the following year, B begins individual psychotherapy with another clinician. He later enters into a romantic relationship with a girl a few years younger than himself and soon also establishes a good relationship with her family.

Some withdrawn behaviours remain in B’s life, including a daily need for a few hours of solitude and video gaming. These behaviours worry his parents, although they recognise that B is now able to place them within a more conscious and regulated framework.

In the final sessions, the work with the parents focuses on their capacity to remain present without intruding, to trust transformative processes that often do not unfold according to a linear timetable, to tolerate uncertainty, and to maintain a symbolic presence in their son’s internal world without overwhelming him. We say goodbye with my availability to meet the couple again if and when they feel the need for further consultation.

Conclusions

I thought it would be useful in this paper to present several experiences of psychotherapy with parents of socially withdrawn adolescents who had refused to meet a psychotherapist. The parents’ representation of their withdrawn child was the focus of the therapeutic intervention. I have tried to clarify how these adolescents are often perceived in unrealistic ways. They are not passive: they are alive, intensely emotional, and often persecuted by unbearable internal states.

At the end of compulsory schooling, the only point of contact with the outside world imposed by society, young people with hikikomori disappear into the reassuring darkness of their rooms, altering the family rhythm in order to survive. Parents who still preserve an internal image of their child as a subject endowed with an inner world will eventually seek help. What they bring to the therapist is a tangle of contradictory emotions, catastrophic anxieties, and a fragile hope for transformation.

Indirect psychotherapy attempts to offer a path beyond this psychic impasse by supporting feelings of failure without judgement, helping parents to see their child as he or she really is and allowing themselves, in turn, to be seen. Only through this mutual recognition can the family begin to emerge from the psychic retreat that has enveloped everyone (Steiner, 2011).

The families presented in the vignettes in this article had lived for months in anguished silence. The only sign of the adolescent’s presence was the rhythmic sound of the computer keyboard behind a closed door. The image evokes a couple listening to the muffled sounds coming from the maternal womb, but terrified that psychic birth may never take place.

Each of the adolescents in the stories presented here experienced failures in real life as catastrophic and shame as unbearable. Psychic withdrawal expresses a request that is difficult to articulate: to be cared for, to rest, to regress, to experience amae like small children (Ranieri & Loscalzo, 2023).

Through the therapeutic process, the parents began to understand how ambivalent feelings towards their child, projections, and expectations arising from their own needs for redemption had compromised their capacity to respond to the adolescent’s emotional needs. Parents who are emotionally unavailable, excessively idealising, intrusive, or who make an excessive narcissistic investment in their child may hinder the formation of a cohesive sense of self.

Unable to find the affective resonance needed to support developmental tasks, the adolescent will seek in psychic withdrawal a defensive system that does not allow him or her to grow, but at least prevents psychological fragmentation. The adolescent will find refuge in an omnipotent and false mental space capable of creating a sense of security while at the same time providing pleasure (De Masi, 2006).

In indirect psychotherapy, parents find a space for dialogue that attempts to foster a new understanding of both their own psychic reality and that of their child. Therapeutic work offers an opportunity to “think the unthinkable” (Coltart, 2017), at least sufficiently to accompany the young person — and themselves — towards the resumption of a developmental process.

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