The best of both worlds: Avatar-assisted therapy offers the benefits of therapist-assisted and Internet-based interventions

Avatar-assisted therapy (AAT) for substance use disorders is the focus of an interesting article by Gordon et al. (1), which appears in the current issue of the American Journal of Drug and Alcohol Abuse. In AAT, participants select a digital character that functions as a representative of their identity in an Internet-based virtual treatment environment. A key advantage of AAT is that in-person attendance is not required to receive counseling, which may increase treatment reach and access by attenuating barriers associated with lack of provider proximity and transportation limitations. Studies have shown that certain area-level characteristics such as living in counties with a higher percentage of black, rural, or uninsured residents (2) and greater socioeconomic deprivation (3) are associated with reduced access to substance abuse treatment.Moreover, recent findings from the National Survey on Drug Use and Health have indicated that among individuals who needed drug or alcohol treatment but did not receive it, common reasons for not receiving treatment included: the belief that treatment might have a negative impact on employment (16.1%), transportation limitations or lack of proximal access to preferred treatment (11.8%), inability to find their preferred type of treatment (10.8%), not wanting others to find out that they were receiving treatment (9.6%), and/or the belief that receiving treatment might cause neighbors or communitymembers to have a negative opinion of them (8.3%) (4). AAT offers the ability to address these commonly reported treatment barriers, and reach even the most vulnerable groups. An important feature of AAT is anonymity (5). Group counseling participants can choose to remain anonymous to each other, which may be appealing to individuals who fear the stigma associated withmental health and substance use disorders. Itmay also be possible tomaintain some level of participant anonymity with counselors, even when identifying information is made available to the clinic. Likewise, the selection of avatars that donot alignwith actual physical characteristics, such as skin color, may eliminate the potentially negative impact of implicit bias, which is known to be present among health-care providers (6). The anonymity offered with AAT may help people to feel more comfortable seeking treatment, and treatmentmay be relatively free of biases associated with skin color and other characteristics. Previous intervention research with avatars has focused largely on the treatment of mental health problems (5), and it seems logical to extend this approach to the treatment of substance use disorders. Gordon et al. (1) are among the first to evaluate the feasibility of using AAT to deliver substance abuse treatment. Key study outcomes were rates of treatment completion, drug positive urine screens, and re-arrest during treatment. Nearly half of participants completed the required 16 treatment sessions, which the authors noted is comparable or better than completion rates in other treatment studies (7). Those who completed treatment were less likely to have positive urine screens than non-completers, and no participants were arrested during treatment. Notably, most participants reported that they were interested in AAT because of transportation concerns and interest in technology, with a substantial minority who reported interest due to childcare issues and preference for anonymity. Findings provide initial evidence of feasibility and acceptability, though randomized trials are needed to evaluate the effectiveness of AAT relative to standard treatment approaches. To date, most technology-based interventions for substance use disorders have been automated, self-paced programs such as online educational modules that provide standardized feedback to patients based on their responses (8–10). Automated treatment approaches are effective, convenient, and low cost (i.e., no physical space or treatment provider required) and therefore have the potential for wide reach and impact. However, automated approaches may not be optimally tailored to the needs of the individual, and initial research suggests that having