Experiences from AVATAR therapy – Conversing with Voices – Highlights from RCPsychIC 2019

Posted on:August 22, 2019
Last Updated: December 7, 2021
Time to read: 3 minutes

This article is a summary of the talk by Prof Thomas Craig at the RCPsychIC 2019.

1. Patients who dialogue with voices get caught in destructive communication patterns that have a detrimental effect on their social functioning.[Corstens D et al., 2012]

2. The voice dialogue method was developed to support the voice-hearer in developing a more constructive communication relationship by talking directly to voices to explore their motives and discover different ways of relating to them.

3. A new therapy called AVATAR has been designed to treat auditory verbal hallucinations, and an RCT of AVATAR therapy showed considerable clinical benefit for patients.[Craig T et al., 2018]

4. The phenomenon behind the voice heard by the patient is that of a distorted interpersonal relationship. In AVATAR therapy, computer software allows the therapist’s voice to be transformed to sound as close as possible to that of the voice the patient hears.

5. The relational approach allows the voice-hearer to have a face-to-face interaction with a digital representation (avatar) of their persecutor (voice heard) and the therapist switches between speaking as the therapist and as the avatar.

AVATAR therapy belongs to a new wave of relational approaches but, uniquely, the voice-hearer’s experiences are brought into therapy in a new way, allowing a face-to-face interaction with a digital representation (avatar) whose speech closely matches the pitch and tone of the persecutory voice. The therapist (switching between speaking as therapist and as avatar) facilitates a dialogue in which the voice-hearer gradually gains increased power and control within the relationship, with the initially omnipotent voice loosening its grip over the hearer by becoming more conciliatory over time.

6. In a pilot study of 6-8 sessions with 12 patients, five patients who had heard voices for many years reported they stopped hearing voices at the end of the therapy, and three patients maintained this at a 3-month follow-up. A total of 1–3 patients experienced desensitization and assertiveness in taking control.

7. A single-blind RCT of AVATAR therapy showed the treatment was more effective than supportive counseling in reducing the severity of persistent auditory verbal hallucinations, determined by a greater reduction in the Psychotic Symptoms Rating Scales Auditory Hallucinations (PSYRATS-AH) total score at 12 weeks.[Craig T et al., 2018 ]

The trial involves a sample of people suffering from persistent psychoses who reported unremitting and very distressing auditory hallucinations for at least the previous 12 months, despite regular supervision and continuing pharmacological treatment. More than a third of all patients across both therapy groups had a clinical record of treatment resistance and were prescribed clozapine before the start of the study.

8. Around 21% of patients declined the offer to take part in the trial. The therapy dropout rate for AVATAR was less than for supportive counseling, and there were no adverse events related to the treatment.

9. Limitations to the study arise with patients who hear multiple voices as a therapist can only work with one voice at a time. A therapist’s accent can also limit the benefit of the therapy if the avatar does not represent the voice of the persecutor closely.

10. A new multi-center trial (N=345) will soon begin across the UK for a three-arm study in London, Manchester, and Glasgow using new software.