AVATAR therapy: a promising new approach for persistent distressing voices
Authors: Tom K.J. Craig
Journal: World Psychiatry (2019)

AVATAR therapy was invented and first described by J. Leff and colleagues1. The therapy involves a three-way conversation between therapist, patient and a digital simulation ("avatar") of one of his/her hallucinated voices. The avatar comprises a visual representation of the agent that the patient believes is responsible for the voice and uses a speech transformation software to change the therapist's voice into a close match of the vocal characteristics (e.g., tone and pitch) of the voice that the patient has chosen for the therapy. Therapy takes place over 6-8 short sessions of approximately 45 min, of which around 15 min are spent in dialog with the avatar, and the rest reviewing the experiences of the previous week, planning the session and reviewing the experience after the dialog is complete. The therapist, sitting in a room remotely from the patient, speaks either as him/herself or in his/her transformed voice as the avatar. The patient sits in front of a monitor on which the avatar appears. Starting with verbatim copies of what the patient reports hearing from his voices, the therapist adjusts what the avatar says according to the unfolding dialog, in which the patient is encouraged to confront the avatar and, through the dialog, to get to a point where it is no longer intimidating and may even become encouraging and supportive. The origins of the approach lie in dialogic therapies2-4 and is based on the observation that voices are best understood not simply as misattributions of internal thoughts, but represent hallucinated social entities that have personal relevance, meaning and purpose5, 6. Thus, the content of therapy is based on a formulation that takes account of the person's beliefs about the identity, power and malevolence of the voices. It includes consideration of whether the voice is of someone he/she knows and whether what it says echoes earlier difficulties in relationships, as for example experiences of being bullied, shamed or humiliated. The therapy proceeds in two broad phases7. The first three sessions focus on assertively standing up to the avatar and rejecting its onslaught. The content of the second phase (sessions 4 through 6) is more variable, as it is based on a formulation of what needs to change in the relationship and what might persuade the avatar to take a more conciliatory and accepting view of the person. Strategies to improve self-esteem have turned out to be a key target, both as an end in themselves and in the understanding of the origin and maintenance of the voice. There have now been two pilot studies comparing AVATAR therapy to a waiting list control1, 8 and one powered controlled trial comparing AVATAR therapy to a supportive counseling intervention9. All have shown benefit over the control condition in terms of reduced frequency and severity of voices at 12 weeks (all voices, not only the one selected to create the avatar). The larger trial9 also showed that the early benefit was sustained at 24 weeks, although the comparison supportive counseling group also improved, so that the residual difference between the two arms was not statistically significant at that point. It is worth emphasizing, however, that it was the improvement in the control condition that accounted for this apparent loss of effect and not a dissipation of effect of AVATAR over the longer follow-up9. The results of these studies are extremely encouraging and have generated a huge worldwide interest among therapists, patients and their families. Together, they suggest a significant advance in the treatment of psychosis. There is, however, still some way to go before the therapy is available beyond the research setting. Some steps towards this are mundane, albeit time consuming, such as ensuring that the software has the necessary regulatory approvals for use outside of research and distilling the experience of the research into manuals and training programmes. Both are currently underway. Another mundane consideration is the technological platform required to deliver the therapy. In principle this is not a significant challenge, as the specialized software runs on standard desktop and laptop computers with a Microsoft operating system, and there is no requirement of more elaborate or expensive immersive virtual reality equipment. However, the approach requires the use of two rooms, which can be a challenge to find in a busy outpatient clinic, and the host health care organization has to consent for the therapy computers to be connected using their ethernet or wireless facilities, with local protocols in place to manage confidentiality and what they wish to be recorded from therapy sessions. Beyond these practical considerations is the availability of clinical staff with the level of expertise required to safely deliver therapy. There is no doubt that the therapy is challenging, both for patients and the therapist and, although there were no adverse events attributed to the therapy in the trials, it is obvious that AVATAR interventions may frighten and harm, deliberately or inadvertently. The therapists in the three studies were all experienced clinicians, some with specific psychological therapy skills for psychosis. On the other hand, in our trial, substantial improvements occurred as early as the third session, raising the possibility that, for some people, the straightforward exposure and assertiveness component was sufficient. If this can be substantiated in future work, and rapid responders can be identified in advance, it would enable the therapy to be delivered by a much wider workforce, with, of course, appropriate training and supervision. A further consideration is the timing of the therapy within the wider envelope of care for psychosis. To date, the therapy has been delivered as a "stand alone" treatment with a focus entirely on the hallucinated voices. Participants were only included if they agreed to remain on their routinely prescribed medication and were not receiving a psychological therapy other than those provided by the research. In clinical practice, it might be more appropriate to consider AVATAR therapy as one component of a wider psychological intervention. For example, in many cases voices were accompanied by persecutory beliefs and consequent social difficulties. It struck us clinically that, for these participants, the timing and impact of AVATAR therapy would have been better if delivered as a component of a therapy plan that also addressed these wider problems. Moreover, the focus to date has been on people suffering from treatment resistant auditory hallucinations in the context of long-standing illness. It is not clear whether the intervention would be as effective in younger people experiencing their first episode of illness. Here, the personification of the voices is often less fixed or elaborated, possibly making the evolution of a coherent dialog more difficult to attain. Finally, while the benefits seen in all three studies to date are a reasonable basis for wider dissemination, there is no doubt that further research is also needed. Larger multicentre replications are necessary before organizations such as the National Institute for Health and Care Excellence (NICE) will include AVATAR therapy in their recommendations, and other studies will be needed to clarify the subgroup of patients who can benefit from the simpler first phase treatment alone. Studies using new virtual reality headsets may replace the need for two rooms and perhaps open the way to deal with more than one voice at a time. To conclude, while there is much to be done to take the existing research to routine care, there is every reason to be optimistic. The technology is relatively inexpensive and enough is known to provide training. The immediate practical obstacles are likely to be resolved shortly, and preparation for dissemination is underway. In the longer run, it seems likely that AVATAR therapy will be provided as one component of wider psychological therapy for psychosis, possibly alongside other digitally-enhanced approaches for paranoia and cognitive impairment.