More Evidence 'Avatar' Therapy Silences Voices in Schizophrenia

Megan Brooks

November 28, 2017

More evidence shows "avatar" therapy can help reduce auditory hallucinations in people with schizophrenia when the patients are provided with usual treatment.

"Our study provides early evidence that avatar therapy rapidly improves auditory hallucinations for people with schizophrenia, reducing their frequency and how distressing they are, compared to a type of counseling. So far, these improvements appear to last for up to 6 months for these patients," lead author Tom Craig, PhD, from King's College London and the South London and Maudsley NHS Foundation Trust, United Kingdom, said in a statement.

The study was published online November 23 in Lancet Psychiatry.

Regaining Control

Avatar therapy, which is experimental, involves a face-to-face discussion between a person with schizophrenia and an avatar that represents their auditory hallucination.

With avatar therapy, the patient chooses a digital representation (or "avatar") that best resembles what they picture their phantom personality looks and sounds like. The therapist ― sitting in separate room and switching between speaking as therapist and as avatar ― facilitates a conversation between the patient and the avatar. In that conversation, the patient gradually gains power and control within the relationship, "with the initially omnipotent voice loosening its grip over the hearer by becoming more conciliatory over time," the authors write.

In a pilot study of 26 patients with treatment-resistant psychosis who reported experiencing auditory hallucinations, those who received six half-hour sessions of avatar therapy reported a significant reduction in the frequency and volume of the internal voices ― and three reported that the voices had disappeared altogether.

The latest study ― the first large-scale randomized controlled trial of avatar therapy ― corroborates results from the pilot study, the researchers note.

Participants included 150 adults with long-standing schizophrenia who had suffered persistent and distressing auditory hallucinations for more than a year, despite standard treatment.

All participants continued to receive their usual treatment throughout the trial. Most participants had paranoid schizophrenia. All were taking antipsychotic medication, with more than a third receiving clozapine. Half were randomly allocated to avatar therapy delivered in six weekly sessions, and half received six weekly supportive counseling sessions (control).

At 12 weeks, the reduction in total score on the Psychotic Symptoms Rating Scales Auditory Hallucinations (the primary outcome) was significantly greater for the patients who underwent avatar therapy than for those who received supportive counseling (mean difference, -3.82; 95% confidence interval [CI], -6.70 to -0.94; P < .0093), with a large effect size (Cohen's d = 0.8). Avatar therapy also led to positive changes in appraisals of hallucinatory voice characteristics, such as its perceived omnipotence.

The improvements achieved with avatar therapy were maintained at 24 weeks' follow-up. However, the supportive counseling group continued to improve, such that there were no significant between-group differences by week 24.

Nine participants reported a complete absence of voices during the week prior to the 12-week assessment (seven in the avatar group and two in the supportive counseling group), and 14 reported not hearing any voices at 24 weeks (eight in the avatar group and six in the counseling group).

There was no evidence of any adverse events attributable to either therapy.

"A large proportion of people with schizophrenia continue to experience distressing voices despite lengthy treatment, so it is important that we look at newer, effective, and shorter forms of therapy," said Dr Craig.

"Traditional cognitive behavior therapy for psychosis is a lengthy therapy that is delivered by highly trained therapists and is, consequently, a scarce resource, which achieves small to moderate effects on auditory verbal hallucinations," the investigators write.

"Results from our study suggest a benefit for briefer therapies that employ digital representations of voices in dialogue and are focused on specific target processes, which could be incorporated within a broader therapy (such as cognitive behavior therapy for psychosis) or offered as a standalone approach."

The researchers caution that the study was conducted at a single treatment center by skilled therapists who had substantial expertise in the psychological treatment of psychosis. This limits generalization of the results to other centers or to delivery of the therapy by a wider mental health workforce.

They say more research is needed to optimize the way avatar therapy is delivered and to show that it is effective in other settings. The researchers plan to do a cost-effectiveness analysis and to dig deeper into the mechanisms of how avatar therapy reduces symptoms.

Powerful Method, Questions Remain

"Given that many of the participants in the study had been hearing voices for 20 years or more, such improvements should not be underestimated," write Ben Alderson-Day, PhD, from Durham University, United Kingdom, and Nev Jones, PhD, from the University of South Florida in Tampa, in a linked comment.

They note that although the results are "encouraging," significant differences between the group that received avatar therapy and the control group were no longer evident at 24 weeks and that roughly equal numbers of participants in the two groups reported not hearing voices at the end of the trial.

"Important questions therefore remain regarding the role of avatar therapy in the resolution of ostensibly persistent auditory verbal hallucinations, and mechanisms of action that potentially contributed to remission for some participants versus quantitative reductions in distress for others," write Dr Alderson-Day and Dr Jones.

"Understanding the patient experience of the therapy ― and the subjective effect of the virtual interaction ― is crucial. Avatar therapy shares a therapeutic focus with a range of methods that emphasize interaction with voices, such as Relating Therapy and voice dialoguing.

"Technology can both obscure and enhance our view of reality, but in the case of AVATAR it seems to provide a powerful method of personifying and externalising an otherwise internal and often intrusive phenomenon....

"We should applaud the efforts of the avatar team and the considerable benefits they have enabled for voice-hearers in their trial, but put simply, the question now is this ― how does the conversation continue?," the authors of the comment note.

The study was funded by the Wellcome Trust. Two of the authors have patents pending on the AVATAR system. A full declaration of interests is listed in the original article.

Lancet Psychiatry. Published online November 23, 2017. Full text, Comment

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