Relating behaviours and therapeutic actions during AVATAR therapy dialogue: An observational study

Abstract

Objectives AVATAR therapy is a novel relational approach to working with distressing voices by engaging individuals in direct dialogue with a digital representation of their persecutory voice (the avatar). Critical to this approach is the avatar transition from abusive to conciliatory during the course of therapy. To date, no observational study has examined the moment‐to‐moment dialogical exchanges of this innovative therapy. We aim to (1) map relating behaviours between participants and their created avatars and (2) examine therapeutic actions delivered within AVATAR dialogue. Method Twenty‐five of the fifty‐three AVATAR therapy completers were randomly selected from a randomized controlled trial (Craig et al. The Lancet Psychiatry, 5, 2018 and 31). Seventy‐five audio recordings of active dialogue from sessions 1 and 4 and the last session were transcribed and analysed using a newly developed coding frame. Inter‐rater reliability was good to excellent. Results Fine‐grained analysis of 4,642 observations revealed nuanced communication around relational power and therapeutic activity. Early assertiveness work, reinforced by the therapist, focussed on increasing power and distancing. Participants’ submissive behaviours reduced during therapy, but the shift was gradual. Once the transition to a more conciliatory tone took place, the dialogue primarily involved direct communication between participant and avatar, focussing on sense of self and developmental and relational understanding of voices. Conclusions AVATAR therapy supports voice‐hearers in becoming more assertive towards a digital representation of their abusive voice. Direct dialogue with carefully characterized avatars aims to build the voice‐hearers’ positive sense of self, supporting the person to make sense of their experiences. Practitioner points AVATAR therapy enables voice‐hearers to engage in face‐to‐face dialogue with a digital representation (‘avatar’) of their persecutory voice. Fine‐grained analyses showed how relating behaviours and therapeutic actions evolve during active AVATAR therapy dialogue. Carefully characterized avatars and direct therapist input help voice‐hearers become more assertive over the avatar, enhance positive sense of self, and support individuals to make sense of their experiences.

Participants’ experiences of AVATAR therapy for distressing voices: a thematic qualitative evaluation

“…Participants’ views on acquisition of new strategies to deal with their distressing voices were also in line with previously identified therapeutic targets [ 5 ] and changes in relational behaviours with the avatar [ 14 ]. Improving self-confidence, (re) building sense of power and control over the voices by standing up to them, and improving their understanding (e.g., voices part of oneself, internal thoughts, association with mood) were the strategies commonly endorsed by participants.…”

“…The insights from this qualitative study together with analysis of the therapy process [ 5 , 14 ] are informing the ongoing evolution of AVATAR therapy. Following the success of the first fully-powered randomised trial [ 8 ] a multi-site trial is currently underway focussing on optimisation and implementation of the approach, which includes training a cohort therapists to deliver therapy in frontline services.…”

“…Different aspects of AVATAR therapy have been examined, including its efficacy [ 8 ], key therapy targets [ 5 ], reduction of subjective in-session anxiety levels and role of sense of voice presence [ 11 ],and changes in dialogue dynamics and content [ 14 ]. However, a qualitative exploration of the person’s experience of AVATAR therapy is crucial to better understand the intervention’s perceived helpfulness and impact, and to optimise its delivery.…”

Unsupervised Machine Learning Driven Analysis of Verbatims of Treatment-Resistant Schizophrenia Patients Having Followed Avatar Therapy

“…Considering the variety of potential interactions that the therapist must employ during the immersive session to personalize the experience for each patient, it is possible that this provides a distinction between the confrontational techniques classified in the blue cluster and those in the red cluster. As indicated in O’Brien et al (2021), in AT, the therapist must consider a formulation to inform the direction of the therapy as well as quickly responding as the characterized avatar [ 42 ]. Several studies outline the use of direct confrontation in psychotherapy as well as empathetic confrontation.…”

Proof of Concept for Efficacy of VR-based Self-Attachment Intervention in a Non-Clinical Population

“…Its huge potential to treat some mental illness and strengthen wellbeing has been investigated by many research groups across the globe [16][17][18] . This technology has been transformative in alleviating several forms of phobias, psychosis and post traumatic stress disorder (PTSD) through VR exposure therapy combined with cognitive enhancement techniques [19][20][21][22][23][24] . The results have been so promising that a recent VR implementation in the treatment of phobias and psychosis has been named "gameChange" by the researching team 19,20 .…”