The role of characterisation in everyday voice engagement and AVATAR therapy dialogue

Abstract

Background Voices are commonly experienced as communication with a personified ‘other’ with ascribed attitudes, intentionality and personality (their own ‘character’). Phenomenological work exploring voice characterisation informs a new wave of relational therapies. To date, no study has investigated the role of characterisation in behavioural engagement with voices or within psychological therapy for distressing voices. Methods Baseline characterisation (the degree to which the voice is an identifiable and characterful entity) of the dominant voice was rated (high, medium or low) using a newly developed coding framework, for n = 60 people prior to starting AVATAR therapy. Associations between degree of characterisation and (i) everyday behavioural engagement with voices (The Beliefs about Voices Questionnaire-Revised; n = 60); and (ii) interaction within avatar dialogue [Session 4 Time in Conversation (participant–avatar); n = 45 therapy completers] were explored. Results Thirty-three per cent reported high voice characterisation, 42% medium and 25% low. There was a significant association between characterisation and behavioural engagement [H(2) = 7.65, p = 0.022, ɛ2 = 0.130] and duration of participant–avatar conversation [F(2,42) = 6.483, p = 0.004, η2 = 0.236]. High characterisation was associated with increased behavioural engagement compared with medium (p = 0.004, r = 0.34; moderate effect) and low (p = 0.027, r = 0.25; small−moderate effect) with a similar pattern observed for the avatar dialogue [high v. medium: p = 0.008, Hedges’ g = 1.02 (large effect); high v. low: p = 0.023, Hedges' g = 1.03 (large effect)]. No differences were observed between medium and low characterisation. Discussion Complex voice characterisation is associated with how individuals interact with their voice(s) in and out of therapy. Clinical implications and future directions for AVATAR therapy and other relational therapies are discussed.

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

“…Voice‐hearers might benefit from AVATAR therapy primarily because of the opportunity to habituate to, and assert their needs to a persecutory voice under the guidance of a well‐attuned therapeutic relationship, or it could be that specific therapeutic actions, such as unfolding relational and developmental understanding of voices during the dialogue, are fundamental to address distress. A new trial (http://www.isrctn.com/ISRCTN55682735) is planned to examine this question and explore moderators of treatment efficacy, such as complexity of characterization of the dominant voice, which we already know is associated with engagement in voice dialogue (Ward et al., 2021).…”

Avatar Therapy Model and Ethical Principles in the Treatment of Auditory Hallucinations in Patients with Schizophrenia

“…Recently, virtual reality therapies have been recommended to treat various psychiatric disorders, including schizophrenia spectrum disorders (Bisso et al 2020). The Avatar therapy model, which can be categorized within virtual reality therapies, is also a novel therapy model in which interpersonal relationship-based psychotherapeutic processes are implemented (Ward et al 2022).…”

“…In addition to the widespread use of virtual reality technologies in the treatment of anxiety, fear, and phobia, it is also known that they are used in the treatment of other mental disorders such as eating disorders, obsessive-compulsive disorder, and schizophrenia (Vardarlı 2021). The avatar therapy model is a virtual reality therapy model based on interpersonal relationships and designed to make sense of the mechanism of auditory hallucinations in a person's life (Ward et al 2022). Virtual reality therapies, among other new-world technologies, are likely to be preferred in the coming years over costly treatment options for treating mental disorders that are difficult to understand using traditional therapy models.…”

“…In summary, the therapist communicates with the patient through the avatar created by the software. The communication of the avatar makes the situation more realistic for the person by moving away from the amateur form of the therapy flow (Ward et al 2022). Based on the information about hallucinations obtained from structured sessions, the therapist continues the dialog, the intention here is not to cause confusion on the patient in the first place and to prepare the ground for further processes.…”

Optimising AVATAR therapy for people who hear distressing voices: study protocol for the AVATAR2 multi-centre randomised controlled trial

“…voices with ascribed attitudes, intentionality, and personality (their own 'character'). Ward and colleagues [21] found that one third of individuals in their AVAT AR therapy sample reported a highly characterised dominant voice (e.g. voices associated with a family member or identifiable 'stranger' with a consistent background and personality).…”