Could Anime Therapy help young Kiwis gain confidence?

With her pink-tinged pigtails, high-pitched voice and short skirt, Kuruto Nagi is not your typical clinical psychologist. She’s an oversharer and - most awkwardly - she’s not actually real. What Nagi can do, however, is deliver high-quality, evidence-based therapy.

Now in early clinical trials, Anime Therapy uses anime characters as avatars who connect with patients on the other side of the screen.

The brain behind it is Francesco Pantò - an Italian-born, Tokyo-based psychiatrist and self-confessed otaku (hardcore anime fan) who, with his mop of dark hair and avant-garde garb, bears more than a passing resemblance to an anime character himself.

Pantò credits anime and manga with getting him through his own teenage years in football-mad Sicily.

"Sicily is beautiful, I love Sicily, but in my adolescent years, it felt difficult to breathe, to feel like myself. Basically, if you don’t like soccer, you’re without worth," he laughs wryly.

"For me, it was such a struggle. I felt very lonely and without role models.

"Anime made me realise what kind of person I wanted to become".

Pantò developed Anime Therapy after talking with his patients about their favourite shows and characters.

"They would start talking about themselves without realising it," he says.

"Anime and manga are always about characters who have low self-esteem or mental challenges, they are often outcasts. But after battles, they gain confidence and transform into heroes."

The psychiatrist came to believe Anime Therapy had the potential to overcome some of the limitations of traditional counselling.

"When you are the therapist, you have to maintain professional distance, you don’t disclose your personal experiences because you need to have boundaries.

"But when you think about it, why do people trust each other? When they share their own experiences, that’s when you know someone really understands."

Pantò came up with the idea of using therapeutic characters, each with their own voice, personality, back story, and relatable problems.

"It’s kind of like acting. But at the same time, they [the therapists] are using all their knowledge and experience as mental health professionals."

Patients develop an emotional bond with characters, he says, and it reframes their personal worries as a mutual enemy "to fight together".

"And it’s fun, which makes it more engaging."

The pilot study has just finished its first clinical trial with 20 enrolled patients completing eight sessions, with researchers now recruiting for the second phase.

Ironically, anime and manga are often associated with poor mental health, Pantò says, as the purview of misfits retreating from the "real world" to a fantasy realm.

"People who don’t feel seen or recognised by the environment they live in are often attracted to anime and manga.

"But that’s because it’s so visionary. You can do anything at all, there are no limits."

The story of how a boy from Sicily transformed himself into a Japanese psychiatrist is nearly as improbable as an anime plot-line.

It began when Pantò saw a documentary about Japan on Italian TV.

"It was showing all the good aspects of Japanese society, of course - music, art, fashion and so on - but it was also showing things like the problem of hikikomori [extreme social withdrawal, usually by young men] and people dying at work from overworking. I thought it was so fascinating!"

Pantò was just 10 years old at the time, but informed his surprised mother he would live in Japan one day.

Years later, at medical school in Rome, he became interested in social psychiatry - the cultural influences shaping mental disorders, including the hikikomori phenomenon.

He taught himself Japanese (by memorising a dictionary of thousands of kanji characters) before winning a scholarship to study hikikomori at the University of Tsukuba, north of Tokyo, later qualifying as a psychiatrist - one of just a handful of foreigners to hold a Japanese medical license.

There’s still a huge stigma in Japan towards mental health struggles, which often prevents people from seeking help when they need it. Being a foreign psychiatrist can be an advantage, Pantò reveals.

"[Because] I’m an outsider in Japanese society, I see patients more relaxed and open up more to me."

Pantò hopes Anime Therapy - with its emphasis on entertainment - could also help break down barriers.

His goal is to make it more accessible in future through AI, "specifically trained by mental health professionals to be very safe".

Pantò has launched a start-up, Aniwell, with co-founder Eriko Oodaira, to scale up Anime Therapy.

The potential market is huge, as the need is great. Among 16 to 29-year-olds in Japan, 50 percent report mental distress and nearly 20 percent experience loneliness.

Anime Therapy could give young people the chance to "process their experiences in a safe way" and learn how to deal with real-world problems, says child psychiatrist Dr Hiran Thabrew, from Auckland’s Starship Children’s Hospital.

"Young people are using AI characters as friends, virtual partners or confidantes for managing loneliness, discussing tricky issues and getting validation and support when feeling bad. There is emerging evidence that this is beneficial for some (albeit with associated risks)."

Given the difficulty in accessing in-person therapy, Thabrew says virtual alternatives could play a role.

"However, it's important these approaches are formally evaluated to know they are effective, safe and acceptable to users."

Although Anime has global appeal, Pantò expects that his therapeutic characters (designed for Japanese consumption) would need to be reconfigured for other countries.

Japanese anime therapists draw on common archetypes in manga, including "maternal energy", "delicate male", and "prince-like" - but other cultures value different traits, he says.

"The very important thing is that the character can be an aspirational role model. They are not perfect, they’ve had their struggles, too, but they can give hope."