Avatar Therapy is a therapist-assisted, computer-based intervention in which therapists facilitate a conversation between patients who are experiencing persistent persecutory auditory hallucinations (i.e. hearing voices) and a visual representation of one of the persecutory voices (i.e. the avatar).
Avatar Therapy is delivered over 6 weekly sessions, lasting about 30 minutes each. Patients use a computer program to construct a visual representation of the dominant persecutory voice and select a voice for the avatar. During therapy sessions, patients see the animated avatar on a computer screen and are asked to begin a conversation in which they stand up to the avatar. Therapists sit in another room and provide support in their normal voice and act as the avatar using a computer-transformed voice. Patients can press a red “stress button” if they become too anxious during the session, which replaces the avatar on the computer screen with a relaxing scene and music. Each session is recorded and patients receive a recording of the session on an MP3 player at the end of the session. Avatar Therapy has also been adapted to use virtual reality technology.
Cognitive Behavior Therapy
Persecutory auditory hallucinations
Young Adults (18-30)
Computer-assisted therapy for medication-resistant auditory hallucinations: Proof-of-concept study
Leff J, Williams G, Huckvale MA, Arbuthnot M, Leff AP. The British Journal of Psychiatry. 2013. 202: 428-433. doi: 10.1192/bjp.bp.112.124883
Summary: Researchers recruited 26 patients who had been hearing persecutory voices for at least 6 months from 2 community mental health centers. Participants received Avatar Therapy for 6 weeks (n=14) or were offered Avatar Therapy after 7 weeks of treatment as usual (n=12; TAU). Participants completed assessments of the frequency and disturbing qualities of voices, beliefs about voice omnipotence and malevolence, and depression symptoms at pre-intervention, 1-week post-intervention, pre- and post-TAU period (wait-list control only), and 3 months after the final avatar session. Immediate intervention participants experienced significant reductions in the frequency and disturbing qualities of voices (average reduction: 8.75 points) and beliefs about voice omnipotence, and malevolence (average reduction: 5.88 points) between baseline and 1 week post-intervention. No significant changes were observed in control participants between baseline and 7 weeks. Wait-list participants who received Avatar Therapy (n=8) experienced similar improvements in frequency and disturbing qualities of voices and beliefs about voice omnipotence and malevolence between pre-intervention and 1 week post-intervention to immediate intervention participants. Researchers collected full data at 3 months post-intervention from 14 participants across both groups. Participants experienced significant reductions in all outcomes between baseline and 3 months post-intervention. Participants experienced significant reductions in the frequency and disturbing qualities of voices (average reduction: 12.25 points) and depression severity (average reduction: 4.13) between 1 week and 3 months post-intervention. Three participants experienced cessation of voices at 1-week post-intervention, which was maintained at three months.
Take Away: In this proof-of-concept study, Avatar Therapy improved qualities of persecutory auditory hallucination between baseline and 1 week and baseline and three months.
Avatar Therapy for auditory verbal hallucinations in people with psychosis: A single-blind, randomized controlled trial
Craig TKJ, Rus-Calafell M, Ward T, et al. Lancet Psychiatry. 2017. 5(1):31-40. doi: 10.1016/S2215-0366(17)30427-3
Summary: Through clinician referral, researchers recruited 150 people with a psychotic disorder who had been experiencing auditory verbal hallucinations for at least 12 months. Participants were randomized to receive Avatar Therapy or supportive counseling designed to match Avatar Therapy in terms of dose (6 weekly sessions) and between-session support (participants received a supportive audio recording from the session on an MP3 player). Participants completed assessments of auditory hallucinations; voice frequency; voice-related distress; perceived voice malevolence, omnipotence, benevolence, and power; voice acceptance; psychiatric symptoms; self-esteem; and quality of life at baseline, 3-, and 6-months. On average, participants completed 5.6 sessions of Avatar Therapy and 5.1 sessions of supportive therapy; 103 participants (69%) completed all therapy sessions. Five Avatar Therapy participants and 15 supportive counseling participants completed no sessions. Avatar Therapy participants experienced reductions in auditory hallucinations, voice frequency, voice-related distress, and perceived voice omnipotence between baseline and 3 months that were significantly greater than those experienced by supportive counseling participants. Improvements in auditory hallucinations, voice frequency, and voice-related distress were maintained at 6 months for both groups, and there were no group differences in outcome scores at 6 months. Seven Avatar Therapy participants and 2 supportive counseling participants reported an absence of voices in the past week at 3 months. Eight Avatar Therapy participants and 6 supportive counseling participants reported an absence of voices for the past week at 6 months.
Take away: Participants who received Avatar Therapy experienced reductions in auditory hallucinations and voice related distress, though there we no significant differences between Avatar Therapy and supportive counseling at 6 months.
Virtual reality therapy for refractory auditory verbal hallucinations in schizophrenia: A pilot clinical trial
du Sert O, Potvin S, Lipp O, et al. Schizophrenia Research. 2018. 197. 176-181. doi: 10.1016/j.schres.2018.02.031
Summary: Researchers adapted Avatar Therapy for virtual reality (VR) technology to promote greater patient immersion in conversations with the avatar. For this pilot study, researchers recruited 19 patients with schizophrenia or schizoaffective disorder who had been hearing persecutory voices and had not responded to treatment. Participants were randomized to receive VR-adapted Avatar Therapy for 7 weeks or to a wait-list control group that received VR-adapted Avatar Therapy after 7 weeks of treatment as usual (TAU). Participants completed assessments of auditory verbal hallucination (AVH) symptoms, perceptions of voice malevolence and omnipotence, psychiatric symptoms, and quality of life at baseline and 3 months post-intervention. Relative to TAU waitlist, participants who received Avatar Therapy experienced significant reductions in AVH symptoms, perceptions of voice malevolence and omnipotence, and psychiatric symptoms. Improvements were maintained at 3 months. Number of sessions of Avatar Therapy completed was not significantly related to outcomes.
Take Away: In this pilot, virtual reality avatar therapy delivered produced improvements in AVH symptoms, perceptions of voice malevolence and omnipotence, and psychiatric symptoms that were not observed in a TAU in the wait-list control group.