AVATAR Therapy for Distressing Voices: A Comprehensive Account of Therapeutic Targets

Abstract

AVATAR therapy represents an effective new way of working with distressing voices based on face-to-face dialogue between the person and a digital representation (avatar) of their persecutory voice. To date, there has been no complete account of AVATAR therapy delivery. This article presents, for the first time, the full range of therapeutic targets along with information on acceptability and potential side effects. Interest in the approach is growing rapidly and this report acts as a necessary touchstone for future development.

The Role of Sense of Voice Presence and Anxiety Reduction in AVATAR Therapy

“…More specifically, it analyses the contribution of sense of voice presence, together with a reduction in anxiety and paranoid attributions about the avatar, to significant primary therapy outcomes following AVATAR therapy. In line with the therapeutic targets of AVATAR therapy and main findings of the RCT [ 10 , 30 ], we hypothesised that; (1) the level of sense of voice presence would remain consistently high across the sessions; (2) there would be a significant reduction of anxiety and paranoid attributions across therapy sessions; and (3) better therapy outcomes at 12-week follow-up (as reported in Craig et al, 2018: PSYRATS-total, frequency, distress and BAVQ-R omnipotence) would be associated with; (i) sense of voice presence, (ii) anxiety reduction, (iii) decreased paranoid attributions to the avatar, as well as (iv) the interaction between anxiety reduction and sense of voice presence.…”

“…Creating and interacting with the avatar acts as a powerful validation of the voice-hearer’s experience, indeed many participants commented that the therapists were the first to hear the voice as they experienced it. By seeing and hearing the voice in real time, the AVATAR approach facilitates the activation of fear and offers access to emotion and emotional meaning-making (‘hot’ cognition), and the potential for meaningful change during what is a comparatively brief therapy [ 30 ].…”

“…AVATAR therapy involves two phases: Phase 1 (sessions 1 to 3) focus on exposure and assertive responding; Phase 2 (sessions 4 to last) focus on relational, emotional and developmental processes [ 21 , 30 ]. It offers a unique way for clinicians to understand how voice hearers interact with a realistic representation of their voice.…”

Exploring the Benefits of Virtual Reality-Assisted Therapy Following Cognitive-Behavioral Therapy for Auditory Hallucinations in Patients with Treatment-Resistant Schizophrenia: A Proof of Concept

“…Higher order themes were in line with key therapeutic processes of the interventions. For CBT, these themes were based on the topics discussed during the intervention (e.g., normalization of voices, coping strategies) and for VRT, the themes were based on prior qualitative analyses (e.g., emotion regulation, self-perceptions) [ 34 , 35 ].…”

“…On the other hand, VRT is among a newer wave of dialogical approaches that aim to ameliorate the voice-hearer relationship by encouraging assertive interactions with voices and by negotiating new ways of relating. VRT focusses on repetitive practice in real-time in an emotional-inducing VR environment where patients may dialogue with their distressing voices [ 28 , 29 , 30 , 34 , 35 ]. Although these two therapies overlap in common practice, to our knowledge, no one has integrated both these models to draw on their strengths.…”